Health Assessment Chapter 3 Questions

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

The nurse is conducting a physical examination of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

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 would use the tuning fork to assess for what?

Hearing loss

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?

Inspection, palpation, percussion, auscultation

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

Light palpation

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

Purposeful hourly rounding by the nurse should include which assessments? (Select all that apply.)

Pain Personal needs Position Fall prevention

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

Strength of a reflex

Which illustrates the nurse using the technique of inspection?

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

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

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

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

A nurse is preparing to evaluate an elderly 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?

Braden scale

A nurse, who suffers from a respiratory infection, is preparing to perform a shift assessment on a client when she feels the urge to cough. What is the nurse's best action?

Cough into the inner aspect of the elbow.

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?

Heart murmur

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

Hyperresonant

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.

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

For which of the following assessments would the nurse plan to use deep palpation?

Shape of abdominal mass Size of liver Pulsation of abdominal aorta

A nurse is preparing 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

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

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

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

Up and back

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.

While examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand.

Light palpation is most appropriate to assess the

inflamed areas of skin

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

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

Light palpation

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

Resonance

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

hyperresonance.