NUR 201 - Jensen Ch. 3

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 evaluating the setting for a client's physical examination. The nurse ensures that the setting has which of the following? Select all that apply.

Adequate lighting Quiet surroundings Table for equipment Door or curtain

When performing a physical assessment on an older adult client, what should the nurse consider offering this client?

An extra blanket

The nurse is planning to assess for the presence of lower pitch sounds when examining a client's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

The nurse is planning to assess for the presence of lower pitch sounds when examining a patient's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

When is it necessary for a nurse to change gloves? Select all that apply.

Between tasks and procedures on the same client When going from a contaminated area to a cleaner area After contact with material that contains a high concentration of microorganisms

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

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

Blood-borne pathogens

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

Coin or key

A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?

Color

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

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 before touching the client

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?

Eliminate distracting noises from the environment.

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate?

Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

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 Face shield

What included in personal protective equipment? Select all that apply.

Gloves Gown Mouth, nose, eye protection

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

After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do?

Go back in to complete a physical examination of the skin.

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 is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

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?

Hyperresonant

Light palpation is most appropriate to assess the

Inflamed areas of the skin

When you observe the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing?

Inspecting

The nurse is performing a physical assessment. The nurse does what first?

Inspection

What assessment technique is performed for every body part and body system?

Inspection

Which of the following techniques are used in a physical assessment? Select all that apply.

Inspection Palpation Auscultation

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

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.

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

Low-frequency sounds

As the density of tissue decreases, the percussion note becomes:

Lower pitched

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

Lungs

A nurse recognizes that it is best to begin the objective data collection with which procedure?

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

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?

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

The nurse obtains a flexible tape measure before beginning the physical assessment of a client. For which body system will the nurse use this piece of equipment? Select all that apply.

Nutrition Abdomen Musculoskeletal Peripheral vascular

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

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

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

Ophthalmoscope

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

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

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

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.

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

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following?

Resonance

For which assessment would the nurse plan to use direct percussion?

Sinuses

For which assessment would the nurse plan to use deep palpation?

Size of liver

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

Skin lesion size

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 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 auscultation?

The nurse detects gurgling throughout the abdomen.

Which is an example of inspection? Select all that apply.

The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine.

Which is an example of percussion? Select all that apply.

The nurse notes dullness over the patient's liver. The nurse notes resonance over the patient's thorax. The nurse notes tympany over the patient's lower abdomen.

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

What is the nurse's primary role in subjective data collection?

To improve the client's health status

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate?

Try to minimize position changes.

A nurse performing percussion over the area of the stomach should anticipate hearing which type of sound?

Tympany

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

Up and back

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

Wear clean gloves when administering heparin to the patient

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

Wearing gloves when palpating the tongue, lips, & gums

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last.

Wet the hands. Apply soap. Scrub the hands together vigorously for 15 seconds. Rinse the hands. Dry hands Turn off faucet with paper towel.

When should the nurse perform hand washing? Select all that apply.

When hands are visibly soiled After removing gloves After providing mouth care

A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?

Wood's light

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

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

blunt percussion.

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

bone.

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

goniometer

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.

The most commonly used method of percussion is

indirect percussion.

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

inspection.

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

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

palpation

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

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

wash both hands with soap and water.

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."

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

1½-inch diaphragm.

The nurse understands that the preferred method of hand hygiene is what?

Alcohol-based rub

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

What can the nurse assess using percussion?

Borders of the heart

A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam?

Collect necessary equipment essential to the exam.

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Consult with a clinical instructor.

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

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown

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

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

Fingerpads

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

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

Hearing loss

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

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

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

Latex allergy

A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?

Lie on the back with legs together on the examination table.

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

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

Which measure does the nurse take to prevent transmission of organisms?

Maintains fingernails to ¼ inch or shorter.

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?

Otoscope

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

Palmar surface

For which assessment would the nurse plan to use light palpation?

Papular rash

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

Patient's state of hygiene

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

Resonance

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations

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.

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

The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain?

Tuning fork

The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?

Use the middle finger to deliver two taps

An instructor is explaining the technique for deep palpation, describing it as which of the following?

Using both hands to depress the skin 1 to 2 inches

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which examination?

Vital signs

Which action by a nurse is appropriate before beginning a physical examination of a client?

Wash hands before examination in the examination room

A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?

Wash hands before examination in the examination room.

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

Wear clean gloves 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.

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

dorsal surface of the hand.

To alleviate a client's anxiety during a comprehensive assessment, the nurse should

explain each procedure being performed and the reason for the procedure.

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

percussion

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

percussion.

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

peripheral vascular

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?

use as a drape

To adhere to standard precautions, the nurse should remember to (Select all that apply.)

wash hands before and after patient contact change white coat frequently

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, non-intact 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 antiseptic handrub

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

Which skin characteristics can a nurse observe by using inspection?

Color

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 is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.

False

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action?

Feeling the surface structures using a circular motion

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?

Hyperressonant

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

Inspection, palpation, percussion, auscultation

For which assessment would the nurse plan to use indirect percussion? Select all that apply.

Kidneys Liver Gallbladder

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

Light palpitation

The nurse has completed the physical examination of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the most important thing the nurse should do prior to leaving the room?

Lower the bed height.

The admitting nurse has just met a new client. As the nurse introduces himself, he begins the process of inspection on this client. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

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 injury

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 patient. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

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

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 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

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.

Which is an example of auscultation? Select all that apply.

The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the patient's anterior thorax.

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action?

Wearing gloves to palpate the tongue and buccal membranes

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

stethoscope bell

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

stethoscope bell

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