ch 3 - collecting objective data ; the physical examination

Nurse needs to auscultate The heart sound of the patient who is in a hospital room watching his favorite television show. Before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment?

Ask the client if it would be okay to mute the volume of the TV during the assessment

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?

Ensuring that contact with the skin is maintained

The nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use?

Goniometer

A nurse is beginning the physical exam of the elderly man with chronic obstructive pulmonary disease. Which order should implement before physical assessment techniques with this client?

Inspection, palpitations, percussion, auscultation

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection which which procedure?

Measure the clients vital signs, height, and weight.

The nurse is performing percussion on the clients back to assess the lungs, and hears a loud, low pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance

A client with an inability to read billboards wile driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart

Nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is correct hand placement for this technique?

The middle finger of one hand is placed in the body surface and the other middle finger strikes.

While performing a physical examination of the client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

To determine whether structures filled with air or fluid or solid structure

A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?

Wash hands before examination in the examination room

Which action by the nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpitating the tongues, lips, and gums

A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this patient's anxiety away?

before performing each procedure, explain what it involves and its purpose

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

coin or key

The nurse because her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observed by using inspection?

color

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough,including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

gloves, mask, protective eye goggles, gown

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope to auscultate for which type of sounds?

heart murmur

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and defecating. Which of the following positions would be the most appropriate for the client

knee-chest

A nurse need to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?

lie on the back with legs together the examination table

A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?

lithotomy

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this ?

otoscope

A nurse is palpating a clients chest for vibration as he inhales and exhales. Which part of he hand should the nurse use in this case

palmar surface

A nursing student will soon b graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment >

practice performing a physical examination on a classmate,friend or relative

A nurse needs to examine a client's range of motion in the hip joints. Which client position would be best for this assessment?

prone

A nurse is performing percussion over the area of a client's stomach . The nurse should anticipate hearing which type of sound?

tympany

A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse used confirm the presence of a fungus?

woods light