Ch. 6 Physical Exam (Getting Started)

Standard Precautions

based on the principle that all blood, bodily fluids, secretions, excretions, non-intact skin, and mucous membranes may contain transmissible infectious agents; includes proper hand hygiene and ppe

Universal precautions are primarily designed to protect the health care worker from what? a) musculoskeletal injuries b) respiratory diseases c) STDs d) blood-borne pathogens

d) blood-borne pathogens

What is a physical exam?

it is a process to obtain objective data from the patient

Tangential Lighting

optimal for inspecting structures such as the JVP, the thyroid gland, and the apical pulse; it casts light across body surfaces that shows contours, elevations, and depressions

What is the purpose of a physical exam?

to determine changes in a patient's health status and how to respond to a problem as well as promote healthy lifestyle and well-being

Reflect on approach to the patient

-as you enter the room; identify yourself as a nursing student -appear calm and organized even when you feel inexperienced -be straightforward -make the patient feel comfortable -spend extra time as needed -explain to the patient what is happening -avoid interpreting your findings

When do you perform hand hygiene?

-before touching a patient, even if gloves are worn -before exiting the patient's care area after touching the patient or their immediate environment -after contact with bodily fluids or excretions or wound dressings -prior to performing aseptic technique -if hands will be moving from a contaminated body site to a clean body site during patient care -after glove removal

When performing a physical exam, the nurse should examine the body in which order? 1. tongue movement 2. thyroid 3. CVA tenderness 4. heart murmur 5. groin 6. gait

1. tongue movement 2. thyroid 3. heart murmur 4. CVA tenderness 5. groin 6. gait

What is used to gauge central and peripheral nervous system disorders? a) gait b) strength of a reflex c) tuning fork d) heat and cold

b) strength of a reflex

To adhere to standard precautions, the nurse should remember to (select all that apply): a) wear gloves with each patient contact b) wash hands before and after contact c) change white coat frequently d) put on a cover gown when entering a patient's room

b, c

What general goals do you organize your comprehensive or focused examination around (select all that apply): a) ensure the patient's compliance with treatment b) maximizing the patient's comfort c) identifying the patient's medical diagnosis d) enhancing clinical efficiency e) avoiding unnecessary changes in position

b, d, e

The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include: a) "it is important to auscultate the bowel sounds heard with percussion" b) "bowel motility is best heard before percussion" c) "palpation will increase bowel motility and alter the sounds heard on auscultation" d) "it is easiest to hear bowel sounds using this technique"

c) "palpation will increase bowel motility and alter the sounds heard on auscultation"

Equipment used in conducting a physical examination includes a 2 x 2 gauze pad. What is this used for? a) testing facial sensation b) involving the blink reflex c) examining the tongue d) inverting the eyelid

c) examining the tongue

Your lab instructor explains that physical examination relies on what cardinal assessment technique? a) communication b) assessment c) percussion d) organization

c) percussion

The ulnar edge of the hand is highly receptive to which of the following sensations? a) vibrations and moisture b) contour and temperature c) temperature and vibrations d) moisture and contour

c) temperature and vibrations

You are performing a physical examination on a new patient. What would you be assessing if you were testing a patient's sense of smell? a) strength of nerve functioning b) nose c) upper neuron function d) cranial nerves

d) cranial nerves

True or False: the nurse is performing a physical exam and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds

false

True or False: it is recommended that a left-handed examiner adopt a right-sided position

true

True or False: the nurse should use the handle of the reflex hammer to detect the plantar reflex

true