Nurs 235 Ch. 3

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

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

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

percussion

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?

Dorsiflexion of the foot

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled 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

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Balance

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

Bone

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

Coin or key

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?

Complete the forgotten portion of the exam out of sequence.

You are performing a physical examination on a new client. What would you be assessing if you were testing the client's sense of smell?

Cranial nerves

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

Finger pads

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

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

Hand hygiene

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 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 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

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

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

Low-frequency sounds

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.

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 client 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 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 clinic nurse is preparing for a comprehensive assessment on a new client. What action(s) should the nurse take prior to conducting the assessment? Select all that apply.

Provide a comfortable, quiet environment. Ensure sufficient lighting and proper equipment are available. Provide privacy via curtain, door, or blanket. Project professionalism and build rapport.

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 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

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

Strength of a reflex

A nurse is preparing to assess a client's abdomen. Which client position would be best for this assessment?

Supine

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

Tangential lighting

A student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed?

The bell of the stethoscope is used to auscultate bowel sounds.

Which illustrates the nurse using the technique of inspection?

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

Which describes the nurse using the technique of palpation?

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.

What is the principle of percussion?

To create vibration in a body wall

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 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

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?

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

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

Up and back

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

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

Wearing gloves when palpating the tongue, lips, & gums

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

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.

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

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?

deep palpation

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

Light palpation is most appropriate to assess the

inflamed areas of skin

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