Ch. 3 - Collecting Objective Data: The Physical Examination

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

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.

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

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

limit position changes as much as possible

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

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

Which is an example of percussion?

the nurse notes dullness over the client's liver. the nurse notes resonance over the client's thorax, and the nurse notes tympany over the client's lower abdomen

Which describes the nurse using the technique of percussion?

the nurse notes resonance over the individual's thorax

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

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound?

tympany

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

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."

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

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

When entering a client's room, what is the nurse's first action?

ask the client's name and birthdate

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

bone

What can the nurse assess using percussion?

borders of the heart

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 performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

decreased breath sounds unilaterally

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

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

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

dorsal surface

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

At the beginning of the shift, an older adult hospitalized for pneumonia reports shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

immediate

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

ophthalmoscope

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

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?

palpation

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

papular rash

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 needs to examine a client's hip joint. Which client position would be best for this assessment?

prone

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

sinuses

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

tangenital lighting

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

temperature and vibrations

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.

What is the principle of percussion?

to create vibrations in a body wall

It is recommended that a left-handed examiner adopt a right-sided position.

true

A nurse in the community is completing a manual blood pressure assessment. Which action should the nurse take to ensure the assessment is accurate?

turn down the television volume

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

up and back

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

wash both hands with soap and water

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

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.

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?

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

Which of the following is a general procedural rule when performing a complete physical examination?

examine the right then the left side of the body

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?

examining the tongue

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

finger pads

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

resonance

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

size of liver

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

Which describes the nurse using the technique of auscultation?

the nurse detects gurgling throughout the abdomen.

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

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

lower pitched

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.

What auscultation sound would the nurse expect when listening to heart sounds?

rhythmic lub-dub

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

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

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

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?

gloves, gown, face shield

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.

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

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

strength of a reflex

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.

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

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

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

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

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

lungs

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.

breasts, chest and thorax, cardiovascular, groin, hips, & knees, and shins and ankles