NUR 230: Chapter 3 Prepu questions

The nurse would use what part of the hand when assessing temperature during palpation? A)Dorsal surface B)Finger pads C)Ulnar surface D)Palmar surface

A) Dorsal surface

The nurse would use the tuning fork to assess for what? A)Hearing loss B)Eye movement C)Visualization D)Reflexes

A) Hearing Loss

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? A)Light B)Intermediate C)Moderate D)Deep

A) Light

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? A)Snellen chart B)Ophthalmoscope C)Opaque card D)Penlight

A) Snellen chart

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

A)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? A)Eliminate distracting noises from the environment. B)Use good lighting, preferably sunlight. C)Look and observe before touching the client. D)Compare appearance of symmetric body parts.

A)Eliminate distracting noises from the environment.

Which of the following techniques are used in a physical assessment? Select all that apply. A)Inspection B)Palpation C)Auscultation D)Questioning E)Subjectivity

A)Inspection B)Palpation C)Auscultation

Which of the following techniques are used in a physical assessment? Select all that apply. A)Inspection B)Palpation C)Auscultation D)Questioning ESubjectivity

A)Inspection B)Palpation C)Auscultation

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

A)Limit position changes as much as possible

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

A)The nurse detects gurgling throughout the abdomen.

Which describes the nurse using the technique of percussion? A)The nurse notes resonance over the individual's thorax. B)The nurse detects crepitus over the individual's thorax. C)The nurse notes symmetry of the individual's thorax. D)The nurse detects rustling over the individual's thorax.

A)The nurse notes resonance over the individual's thorax.

Which describes the nurse using the technique of percussion? A) The nurse notes resonance over the individual's thorax. B)The nurse detects crepitus over the individual's thorax. C)The nurse notes symmetry of the individual's thorax. D)The nurse detects rustling over the individual's thorax.

A)The nurse notes resonance over the individual's thorax.

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate? A)Turn down the volume if the television or radio is on. B)Turn down the lights in the room. C)Ensure that the client is lying down. D)Ask the client to take deep breaths.

A)Turn down the volume if the television or radio is on.

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? A)Wood's light B)Penlight C)Magnifying glass D)Examination light

A)Wood's light

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 A)hyperresonance. B)tympany. C)dullness. D)flatness.

A)hyperresonance

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? A)Snellen E chart B)Braden scale C)Penlight D)Reflex (percussion) hammer

B) Braden Scale

Which of the following statements is true of the role of inspection in the physical examination? A)It should be performed after auscultation but before palpation and percussion. B)It is often the source of the most physical signs. C)To maximize findings, local inspection should be conducted prior to general inspection. D)The acuity of the client will determine whether general or local inspection should be implemented in the examination.

B) It is often the source of the most physical signs.

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? A)Supine B)Lithotomy C)Standing D)Prone

B) Lithotomy

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? A)Stethoscope B)Otoscope C)Ophthalmoscope D)Sphygmomanometer

B) Otoscope

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

B) bone

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system? A)palpation B)inspection C)percussion D)auscultation

B) inspection

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

B)Alcohol-based rub

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? A)Inspection B)Palpation C)Percussion D)Auscultation

B)Palpation

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? A)nspection B)Palpation C)Percussion D)Auscultation

B)Palpation

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? A)Hyper-resonance B)resonance C)Tympany D)Dullness

B)Resonance

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

B)bone.

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client? A)"It's a policy I have to follow." B)"They help me feel your body parts under your skin better." C)"They make sure that any microorganisms on my hands do not touch your skin." D)"Since we don't know what's wrong with you, I wear gloves to make sure I don't get sick."

C)"They make sure that any microorganisms on my hands do not touch your skin."

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? A)Warm, comfortable room B)Quiet area free of disturbance C)Adequate lighting D)Firm examination bed or table

C)Adequate lighting

A nurse needs to auscultate the heart sounds of a client who is in a hospital room watching his favorite television show. Before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment? A)Leave the television as is, as the client is enjoying his show and being distracted from his pain. B)Ask the client to play some music from his laptop computer instead of watching TV. C)Ask the client if it would be okay to mute the volume on the TV during the assessment. D)Turn off the TV and begin the assessment.

C)Ask the client if it would be okay to mute the volume on the TV during the assessment.

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

C)Blood-borne pathogens

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound? A)Resonance B)Hyper-resonance C)Tympany D)Dullness

C)Tympany

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

C)Wearing gloves when palpating the tongue, lips, & gums

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 A)light palpation. B)moderate palpation. C)deep palpation. D)very deep palpation.

C)deep palpation.

While examining a client, the nurse plans to palpate the temperature of the skin by using the A)fingertips of the hand. B)the ulnar surface of the hand. C)dorsal surface of the hand. D)the palmar surface of the hand.

C)dorsal surface of the hand.

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

D)Balance

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

D)Dorsal surface

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? A)Application of firm pressure when using the bell B)Using the diaphragm to listen to low-pitched sounds C)Using the bell to detect high-pitched sounds D)Ensuring that contact with the skin is maintained

D)Ensuring that contact with the skin is maintained

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? A)Percuss the region before auscultating. B)Palpate the region before auscultating. C)Assist the client to a sitting position. D)Reduce all environmental noise.

D)Reduce all environmental noise.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? A)Percuss the region before auscultating. B)Palpate the region before auscultating. C)Assist the client to a sitting position. D)Reduce all environmental noise

D)Reduce all environmental noise.

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is A)palpation. B)percussion. C)auscultation. D)inspection.

D)inspection.

While performing a physical examination on an older adult, the nurse should plan to A)complete the examination as quickly as possible. B)ask the client to change positions frequently. C)provide only minimal teaching related to health care. D)use minimal position changes.

D)use minimal position changes.

The diaphragm of the stethoscope is used to listen to low-pitched sounds, such as abnormal heart sounds and bruits. True or False

False

A nurse-client relationship established before a physical examination helps to alleviate tension or anxiety that the client is experiencing. True or False

True

During inspection, it is preferable to use sunlight, because fluorescent lights can alter the true color of the skin. True or False

True

Whether to have a physical examination ultimately rests with the client, even though the nurse might have informed the client about the importance of such an examination. True or False

True

_____________________ involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.

inspection