Chapter 3: Techniques of Assessment & Safety

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin." Rationale: One reason to wear gloves is to prevent the transmission of flora from health care workers to clients. Wearing gloves is more than just following a policy. Gloves hinder the ability to discern body parts and positions. Although the client may have a communicable illness, the nurse should not make a statement that could cause the client anxiety about being ill.

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

Light palpation Rationale: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

A nurse recognizes that the best part of the hand to use to palpate for vibration is:

Palmar surface Rationale: The ulnar or palmar surface is the part of the hand used to palpate vibrations. The finger tips are not used to palpate. The dorsal surface is sensitive to temperature and the finger pads are used to detect fine discriminations, pulses, texture, size, consistency, shape, & thrills.

Which of the following is a component of the general survey?

Patient's state of hygiene Rationale: During the general survey, the nurse should note the client's general state of health, build, and sexual development. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath. Watch the client's facial expressions and note manner, affect, and reactions to people and things in the environment. Listen to the client's manner of speaking and note the state of awareness or level of consciousness. Measure height and weight.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise. Rationale: Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the client to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the client in the lying position.

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

Resonance Rationale: Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.

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

Resonance Rationale: Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue.

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub?

Rub the hands and fingers until dry Rationale: Proper technique for using alcohol-based hand rubs is necessary to be effective. The nurse then rubs both hands together, making sure to cover all surfaces of the fingers and hands until they are dry. When an alcohol-based rub is used, all surfaces of the hand must be covered. Alcohol-based hand rub cannot be used when the hands are visibly soiled. Using paper towels to dry the hands is not the proper technique.

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

The diaphragm should be held firmly against the body part. Rationale: The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. Rationale: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland Rationale: Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status?

auscultation Rationale: Auscultation is used to listen to sounds. Because the client has a history of heart problems, the heart sounds will provide the most information. Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness.

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?

reflex hammer Rationale: A reflex is used to assess deep tendon reflexes which are under the control of the neurologic system. A penlight is used to assess pupillary reflexes and aids with tangential lighting. A scoliometer measures the degree of spinal curvature. A pulse oximeter measures oxygen level.

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?

stethoscope bell Rationale: The bell of the stethoscope is used to auscultate low-pitched sounds. Doppler is used to detect pulses and blood flow. A sphygmomanometer is used to measure blood pressure. The diaphragm of the stethoscope is used to auscultate high-pitched sounds.

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape Rationale: During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.

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 Rationale: The nurse can apply an antiseptic hand rub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap.

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 Rationale: After an anal exam, fecal material is tested for the presence of blood. Testing for other organisms requires specialized specimen collection.

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

Dorsal hand surface Rationale: The dorsal or back surface of the hand is most sensitive to temperature and should be used to assess the temperature of the feet of an older adult client with diabetes. The finger pads are sensitive to fine discriminations, pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is sensitive to vibrations, thrills, and fremitus.

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

Fungal infection Rationale: The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

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 Rationale: Because this client has emphysema with a chronic productive cough, it is likely that the nurse will not only come into direct contact with the client's sputum or mucus (a body fluid) during examination of his oral cavity, which requires the use of gloves, but also that sputum will be sprayed on the nurse's face and body, which requires the use of a mask, protective eye goggles, and a gown.

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

Hearing loss Rationale: The tuning fork is used to assess for hearing loss. Reflexes may be checked with a reflex hammer. An ophthalmoscope is used for the eye. An ophthalmoscope and otoscope are used for visualization.

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?

Heart sounds Rationale: The bell of the stethoscope is used to listen to low-pitched sounds such as abnormal heart sounds (heart murmurs) and bruits. The diaphragm is used to listen for high-pitched sounds such as normal heart sounds, breath sounds, bowel sounds, and pulses.

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs. Rationale: Inspection often yields the most signs during an examination. It should begin the examination, and general inspection precedes local inspection. The two are not mutually exclusive and should both be implemented in each examination.

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

Latex allergy Rationale: Latex allergies are more common in nurses and clients frequently hospitalized. Research shows the risk of developing a latex allergy is increased in individuals with increased latex exposure. Nurses and clients who are often hospitalized are not more frequently diagnosed with bunions, inflamed skin, or medication allergies.

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 Rationale: Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath. Rationale: Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the client's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen. Rationale: Auscultation is used by the nurse to assess bowel sounds, such as gurgling throughout the abdomen. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors, such as foul smelling urine. The nurse uses palpation to detect nodules in the breast by the use of touch. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as dullness over the liver.

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

Wear clean gloves when administering heparin to the client Rationale: Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.

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 Rationale: Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?

goniometer Rationale: A goniometer is used to measure degree of flexion and extension of joints. A speculum is used to examine the ear canals. Test tubes are used to measure temperature sensation. A stadiometer is used to measure height.

Light palpation is most appropriate to assess the

inflamed areas of skin Rationale: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular Rationale: A tuning fork has two uses in the physical examination. The most common is to assess hearing however the tuning fork is also used to assess the sense of vibration when completing the neurologic or peripheral vascular assessment. A tuning fork is not used to assess the respiratory, genitourinary or gastrointestinal systems.