Chapter 3

17. 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? A) Heart sounds

A

2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate? A) Ensuring client's privacy by providing an examination gown

A

26. A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A) Inspection

A

28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, I'd really like to have my mom in the room. That's okay, isn't it? How should the nurse best respond to the client's request? A) Of course. There's a chair in the exam room where she can sit.

A

6. The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use? A) Newspaper

A

9. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There's no way I'll let you do that to me!î Which response by the nurse would be most appropriate? A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

A

24. The nurse is evaluating the setting prior to beginning a client's physical examination. The nurse should confirm the presence of which of the following? Select all that apply. A) Adequate lighting C) Quiet surroundings E) Table for equipment F) Door or curtain

A; C; E; F

12. The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate? B) Try to minimize position changes.

B

13. The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position? B) Supine

B

19. A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment? B) The diaphragm should be held firmly against the body part.

B

20. 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 of the following actions? B) Feeling the surface structures using a circular motion

B

21. The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination? B) Speak clearly and slowly when explaining a procedure.

B

27. The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? B) Resonance

B

29. The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client's hand. What action should the nurse perform next? B) Compare the appearance of the client's other hand

B

4. 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? B) Fungal infection

B

7. A nurse practitioner 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? B) Blood

B

8. The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing? B) Joint flexion/extension

B

14. 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 assessment data? C) Dorsal hand surface

C

18. An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? C) ìWhen using the bell, push on it lightly.î

C

23. The nurse is gathering the necessary equipment preparatory to examining a client's ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain? C) Tuning fork

C

25. The nurse is using her finger pads to palpate a client's body part during the physical examination. Which of the following would the nurse best be able to detect? C) Pulses

C

3. 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 which of the following actions? C) Wearing gloves to palpate the tongue and buccal membranes

C

30. A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness? C) Direct percussion

C

5. A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? C) Skin lesion size

C

1. A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam? D) Collect necessary equipment essential to the exam.

D

10. 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 of the following examinations? D) Vital signs

D

11. The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment? D) Face shield

D

15. A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions? D) Use both hands to depress the skin 1 to 2 inches.

D

16. The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? D) Blunt percussion

D

22. The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position? D) Abdomen

D