Week 2: Objective Data
6 The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?
Balance Explanation: The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the client in the seated position. The thorax is assessed in either the sitting or lying position.
12 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 Explanation: 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.
7 Your lab instructor explains that physical examination relies on what cardinal assessment technique?
Percussion Explanation: Note that the physical examination relies on four classic techniques: inspection, palpation, percussion, and auscultation.
14 A nurse is preparing to assess a client's abdomen. Which client position would be best for this assessment?
Supine Explanation: The supine position, in which the client lies down on her back, would be the best position for assessment of the abdomen. The abdomen would be inaccessible in the Sims' position, in which the client lies on her right or left side. The abdomen would be contracted, and thus not assessable, in the sitting and dorsal recumbent positions.
12 Which illustrates the nurse using the technique of inspection?
The nurse detects a fruity odor of the client's breath. Explanation: 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.
17 Which describes the nurse using the technique of palpation?
The nurse notes increased warmth surrounding an abdominal incision. Explanation: The nurse uses palpation to assess the individual through touch, such as to detect increased warmth surrounding an incision. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting the symmetry of the abdomen. Auscultation is used by the nurse to assess bowel sounds. The nurse detects tympanic sounds of the bowel by percussing the abdomen.
20 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 Explanation: The general survey begins immediately when meeting the client and continues throughout the assessment.
6 While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's
bone. Explanation: Flatness is a sound heard over very dense tissue like bone.
7 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
16 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. Explanation: 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.
7 While examining a client, the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand. Explanation: The dorsal surface of the hand is used to palpate body temperature.
3 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. Explanation: Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.
15 The most commonly used method of percussion is
indirect percussion. Explanation: Indirect or mediate percussion is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures.
10 Light palpation is most appropriate to assess the
inflamed areas of skin Explanation: 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).
11 The nurse would use what part of the hand when assessing temperature during palpation?
Dorsal surface Explanation: The dorsal surface is used for temperature. The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus.
18 The nurse is preparing for a physical examination of a client. What should the nurse do first?
Hand hygiene Explanation: The nurse should perform hand hygiene before beginning the physical assessment. This includes prior to gathering equipment. Auscultation and palpitation should not occur until after hand hygiene has been performed.
10 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 Explanation: The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.
16 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. Explanation: The nurse should assist the client to a supine position by instructing the client to lie down with legs together on the examination table. To get the client into the dorsal recumbent position, the nurse gives instructions to lie down, with knees bent, legs separated, and feet flat on the table. In the prone position, the client lies down on the abdomen with head to the side. In the knee-chest position, the client kneels on the table with the weight of the body supported by the chest and the knees.
4 A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?
Light palpation Explanation: 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.
19 You should use the bell of the stethoscope when auscultating what type of sounds?
Low-frequency sounds Explanation: The bell is used with light skin contact to hear low-frequency sounds.
17 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. Explanation: 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.
16 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 Explanation: Skinfold calipers measure skinfold thickness of subcutaneous tissue to aid in establishing a client's percent body fat. A platform scale with height attachment measures height and weight. A metric ruler is used to measure the size of skin lesions. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.
20 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 Explanation: Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.
12 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 Explanation: 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.
19 A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this client's anxiety?
Before performing each procedure, explain what it involves and its purpose. Explanation: Throughout the examination, continue to explain what procedure you are performing and why you are performing it. This helps to ease your client's anxiety. If a urine sample is not necessary, ask the client to urinate before the examination to promote an easier and more comfortable examination of the abdomen and genital areas, although it will not likely ease the client's anxiety. Begin the examination with the less intrusive procedures such as measuring the client's temperature, pulse, blood pressure, height, and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with you and help to ease client anxiety about the examination. Having the client undress and put on an examination gown, although required, is not likely to ease his anxiety.
1 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 Explanation: The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores. The Snellen E chart is used to test distant vision. The penlight is used to view the mouth and throat and to transilluminate the sinuses. The reflex (percussion) hammer is used to test tendon reflexes.
15 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 Explanation: The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens. Disinfecting the stethoscope after touching the client does not answer the question being asked. Placing the stethoscope directly on the client's skin does not answer the question being asked. Nothing noted in the question would require the nurse to wear a personal protection gown.
5 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 Explanation: Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the client in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the client in the sitting position.
14 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 Explanation: While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.
4 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 Explanation: While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.
5 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 Explanation: The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure.
8 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 Explanation: The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds.
17 Which of the following techniques are used in a physical assessment? Select all that apply.
Inspection • Palpation • Auscultation Explanation: The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment. Subjectivity and questioning are not techniques of inspection for physical assessment.
15 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 Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate is not typically used to describe palpation.
13 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 Explanation: 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.
4 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 Explanation: 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.
5 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 Explanation: To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A penlight is used to test pupillary constriction.
8 When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?
Tangential lighting Explanation: Tangential lighting is optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. It casts light across body surfaces that throws contours, elevations, and depressions, whether moving or stationary, into sharper relief.
2 A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?
The middle finger of one hand is placed on the body surface and the other middle finger strikes. Explanation: Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand.
3 Which describes the nurse using the technique of auscultation?
The nurse detects gurgling throughout the abdomen. Explanation: 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.
14 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 Explanation: The nurse uses the percussion technique while performing a physical examination to determine whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is used to feel deep organs or structures covered by thick muscles and to determine tenderness, moisture, and surface skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface.
3 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 Explanation: The general survey begins immediately when meeting the client and continues throughout the assessment.
13 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 Explanation: 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.