Chapter 3: Collecting Objective Data: The Physical Examination.

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? -light palpation -moderate palpation -deep palpation -direct palpation

deep 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? -ophthalmoscope -otoscope -stethoscope -sphygmomanometer

otoscope

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? -serve as a head support -pad the table -collect body fluids -use as a drape

use as a drape

What included in personal protective equipment? Select all that apply. -Gown -Cleaning processes -Special linen -Gloves -Mouth, nose, eye protection

-Gloves -Mouth, nose, eye protection -Gown

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.) -Shape of abdominal mass -Size of liver -Pulsation of abdominal aorta -Texture of a mole -Macular rash

-Shape of abdominal mass -Size of liver -Pulsation of abdominal aorta

A nurse in a clinic is preparing to perform an assessment of the eyes on a new client. What equipment should the nurse gather for this assessment? Select all that apply. -Snellen chart -newspaper -Wood's light -penlight -watch with a second hand

-Snellen chart -newspaper -penlight

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? -Axillary nodes -Thorax -Balance -Cervical spine

Balance

What can the nurse assess using percussion? -Borders of the heart -Movement of the diaphragm during expiration -Strength of the pulse -Rectal distension

Borders of the heart

A nurse is preparing to evaluate an older client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose? -Reflex (percussion) hammer -Braden scale -Snellen E chart -Penlight

Braden scale

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? -Tell the client she may have a friend or family member stay with her during the assessment. -Respect the client's decision and do not press her on the issue. -Explain to the client why the assessment is important and the possibility of missing important findings. -Inform the client that an assessment must be completed in order to provide treatment.

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

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment? -Palpation -Auscultation -Percussion -Inspection

Palpation

How should the nurse place the ear of an adult when using the otoscope? -Down and forward -Up and forward -Down and back -Up and back

Up and back

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's -abdomen. -liver. -bone. -lungs.

bone.

Which of the following techniques are used in a physical assessment? Select all that apply. -Questioning -Inspection -Palpation -Auscultation -Subjectivity

-Inspection -Palpation -Auscultation

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what? -Alcohol-based rub -Use of lotions -Hand washing -Gloves

Alcohol-based rub

Universal precautions are primarily designed to protect the health care worker from what? -Blood-borne pathogens -Respiratory diseases -Musculoskeletal injuries -STDs

Blood-borne pathogens

What physical assessment technique should a nurse use to obtain a pulse on a client? -Light palpation -Moderate palpation -Bimanual palpation -Deep palpation

Light palpation

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? -When the demographic data has been -documented -Upon meeting the client and family members -After the physical examination is completed -As soon as any visitors have left the room

Upon meeting the client and family members

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? -Inform the client that the examination was incomplete and start over. -Proceed as normal with the assessment data collected from the incomplete exam. -Complete the forgotten portion of the exam out of sequence. -Perform the complete assessment at the end of the shift.

Complete the forgotten portion of the exam out of sequence.

The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position? -Range of motion of the spine -Posterior chest excursion -Head and neck range of motion -Dorsiflexion of the foot

Dorsiflexion of the foot

When assessing pulses, the nurse would use which part of the hand for palpation? -Finger pads -Ulnar surface -Palmar surface -Dorsal surface

Finger pads

Which describes the nurse using the technique of auscultation? -The nurse detects foul odor of the urine. -The nurse notes a small nodule in the breast. -The nurse notes dullness over the liver. -The nurse detects gurgling throughout the abdomen.

The nurse detects gurgling throughout the abdomen.

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 -use of moderate palpation with gloves -auscultation of the heart using the stethoscope diaphragm -use of light palpation with an ungloved hand to sense murmur

auscultation of the heart with the stethoscope bell

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 -very deep palpation. -light palpation. -deep palpation. -moderate palpation.

deep palpation.

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? -No washing is needed because hands are not soiled. -Application of an alcohol-based hand rub -Nonantimicrobial soap and water with friction -Hand wash with antiseptic soap

Application of an alcohol-based hand rub

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 client's anxiety? -Have him undress and put on an examination gown. -Perform the genital assessment first to get it over with. -Have him urinate before the examination. -Before performing each procedure, explain what it involves and its purpose.

Before performing each procedure, explain what it involves and its purpose.

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 -Bacteria -Parasites -Fungus

Blood

As a nurse is assessing a client and asking her questions, the nurse notices that the client stops talking and looks up anxiously each time someone passes by in the hallway outside her hospital room. Which nursing intervention would most likely address the client's concern and promote enhanced communication in this situation? -Turn on the television to mask the sound of the conversation -Close the door to the client's room -Provide the client with a blanket to make her feel more secure -Whisper questions to the client to prevent being overheard

Close the door to the client's room

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? -Disinfect the stethoscope after touching the client -Put on a personal protection gown -Disinfect the stethoscope before touching the client -Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface

Disinfect the stethoscope before touching the client

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? -Palmar surface -Dorsal surface -Finger pads -Ulnar surface

Dorsal surface

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique? -Use good lighting, preferably sunlight. -Compare appearance of symmetric body parts. -Eliminate distracting noises from the environment. -Look and observe before touching the client.

Eliminate distracting noises from the environment.

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 -Using the bell to detect high-pitched sounds -Application of firm pressure when using the bell -Using the diaphragm to listen to low-pitched sounds

Ensuring that contact with the skin is maintained

The nurse is preparing for a physical examination of a client. What should the nurse do first? -Hand hygiene -Palpitation -Auscultation -Gather equipment

Hand hygiene

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? -Gowning -Using eye protection -Handwashing -Wearing latex gloves

Handwashing

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? -Bowel -Normal heart -Heart murmur -Breath

Heart murmur

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs? -Flat -Hyperresonant -Tympanic -Resonant

Hyperresonant

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness? -Using alcohol swabs to clean the stethoscope -Draping body areas that are not being assessed. -Limit position changes as much as possible -Hand-washing throughout the exam

Limit position changes as much as possible

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? -Standing -Supine -Lithotomy -Prone

Lithotomy

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? -Sphygmomanometer -Platform scale with height attachment -Skinfold calipers -Metric ruler

Skinfold calipers

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? -Penlight -Opaque card -Snellen chart -Ophthalmoscope

Snellen chart

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique? -One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. -The middle finger of one hand is placed on the body surface and the other middle finger strikes. -The ulnar surface of one hand is placed against the body surface and vibrations are felt. -One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.

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

Which describes the nurse using the technique of palpation? -The nurse notes asymmetry of the individual's abdomen. -The nurse notes increased warmth surrounding an abdominal incision

The nurse notes increased warmth surrounding an abdominal incision

Which describes the nurse using the technique of percussion? -The nurse notes resonance over the individual's thorax. -The nurse notes symmetry of the individual's thorax. -The nurse detects crepitus over the individual's thorax. -The nurse detects rustling over the individual's thorax.

The nurse notes resonance over the individual's thorax.

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 feel for deep organs or structures covered by thick muscles -To determine tenderness, moisture, and the surface skin texture -To observe for abnormalities on the skin's surface -To determine whether a structure is filled with air or fluid or is a solid structure

To determine whether a structure is filled with air or fluid or is a solid structure

It is recommended that a left-handed examiner adopt a right-sided position. True False

True

The nurse is caring for the client who is receiving heparin. The nurse plans to: -Wear a mask when administering heparin to the client -Recap the needle after administering heparin to the client -Wear clean gloves when administering heparin to the client -Perform hand hygiene with alcohol-based gel after administering the heparin

Wear clean gloves when administering heparin to the client

Which action by a nurse demonstrates the correct application of the principles of standard precautions? -Change gloves after each body area is examined -Using an antiseptic hand scrub to cleanse visibly soiled hands. -Wearing a gown, gloves, and mask for the physical exam -Wearing gloves when palpating the tongue, lips, & gums

Wearing gloves when palpating the tongue, lips, & gums

While examining a client, the nurse plans to palpate temperature of the skin by using the -fingertips of the hand. -dorsal surface of the hand.

dorsal surface of the hand.

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit -dullness. -flatness. -hyperresonance. -tympany.

hyperresonance.

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

palpation

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. -Gown -Stethoscope -Nasopharyngeal airway -Gloves -Face shield

-Gloves -Face shield -Gown

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) -Dim the lighting to promote comfort. -Wash hands. -Identify ways to ensure client privacy. -Turn on relaxing music of the client's choice. -Obtain and check needed equipment.

-Wash hands. -Identify ways to ensure client privacy. -Obtain and check needed equipment.

What would be the expected tone elicited by percussion of a normal lung? -Resonance -Dullness -Tympany -Hyper-resonance

Resonance

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client? -Palpation, inspection, auscultation, percussion -Inspection, palpation, percussion, auscultation -Auscultation, percussion, palpation, inspection -Percussion, palpation, inspection, auscultation

Inspection, palpation, percussion, auscultation

You should use the bell of the stethoscope when auscultating what type of sounds? -High-frequency sounds -Sounds that are partially audible without a stethoscope -Abnormal sounds -Low-frequency sounds

Low-frequency sounds

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond? -Explain the importance of the examination and the risks of breast cancer -Comply with the client's request and proceed with the rest of the examination -Insist that the client undress and allow her breasts to be examined, for her own good -Ask the physician to perform the examination

Explain the importance of the examination and the risks of breast cancer

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure? -Allow the client to undress and put on a gown. -Auscultate all necessary body systems to prevent disturbing any organs. -Begin at the head and move in a systematic approach. -Measure the client's vital signs, height, and weight

Measure the client's vital signs, height, and weight

Light palpation is most appropriate to assess the -liver -inflamed areas of skin -bladder -appendix

inflamed areas of skin

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is -inspection. -auscultation. -percussion. -palpation.

inspection.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique? -Risk for impaired skin integrity -Risk for injury -Risk for chronic pain -Risk for infection

Risk for injury

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 ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c,d,e,b,a

Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques? -The nature and elasticity of tissue and body structures influence sound. -High-intensity sounds indicate compromised tissue integrity, lack of tissue density, or both. -Percussion and auscultation findings are more objective than inspection and palpation findings. -Pitch and duration of sound depend on each other and allow for conclusions regarding client health.

The nature and elasticity of tissue and body structures influence sound.

The nursing instructor is teaching nursing students about hand hygiene prior to performing a health assessment. The nursing instructor determines effectiveness of the teaching when the students state that hand hygiene should occur at which point? Select all that apply. -before touching a client -before eating -immediately before glove removal -when hands become visibly soiled -before leaving a client's room

-before touching a client -before eating -when hands become visibly soiled -before leaving a client's room

What is used to gauge central and peripheral nervous system disorders? -Strength of a reflex -Tuning fork -Heat and cold -Gait

Strength of a reflex

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? -Back -Lungs -Abdomen -Neck

Lungs

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client? -Adequate lighting -Warm, comfortable room -Quiet area free of disturbance -Firm examination bed or table

Adequate lighting

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? -Reflex hammer -Tuning fork -Coin or key -Tongue depressor

Coin or key