Chapter 3 Collecting objective data: physical exam techniques

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

Light palpation

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

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an alcohol-based hand rub

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Complete the forgotten portion of the exam out of sequence.

A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?

Explain to the client why the assessment is important and the possibility of missing important findings.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath.

While performing the physical examination of a 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 a structure is filled with air or fluid or is a solid structure

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

Tympany

The nurse is caring for the client who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the client

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

Wearing gloves when palpating the tongue, lips, & gums

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone

the nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination.a. Shins and anklesb. Groin, hips, and kneesc. Breastsd. Chest and thoraxe. Cardiovascular

c, d, e, b, a

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

coin or key

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

deep palpation

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

palpation

What would be the expected tone elicited by percussion of a normal lung?

resonance

How should the nurse place the ear of an adult when using the otoscope?

up and back

The nurse wears gloves for which of the following purposes? Select all that apply.

Prevent transmission of flora from client to client. Limit exposure to body fluids and secretions

A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?

Skinfold calipers

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

balance

When assessing pulses, the nurse would use which part of the hand for palpation?

finger pads

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.

gloves gown faceshield

A 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

The nurse would use the tuning fork to assess for what?

hearing loss

he nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

indirect percussion

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

light

What physical assessment technique should a nurse use to obtain a pulse on a client?

light palpation

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion

A client with an inability to read billboards while 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

A nurse is preparing to assess a client's abdomen. Which client position would be best for this assessment?

supine

Which illustrates the nurse using the technique of inspection?

the nurse detects a fruity odor of the client's breath.

Before beginning a physical assessment of a client, the nurse should first

wash both hands with soap and water.

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

light palpation

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

lungs

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?

blood

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?

deep palpation