Chapter 3

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) Resonance b) Dullness c) Tympany d) Hyper-resonance

A.

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment? a) Prone b) Supine c) Knee-chest d) Lithotomy

A.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? a) Fingerpads b) Ulnar surface c) Palmar surface d) Dorsal surface

D.

When performing a physical assessment on an older adult client, what should the nurse consider offering this client? a) An extra blanket b) A family member in the room c) Elevation of the head of the examination table d) A pillow

A.

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) Firm examination bed or table b) Adequate lighting c) Warm, comfortable room d) Quiet area free of disturbance

B.

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.

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population? a) Bunions b) Latex allergy c) Medication allergies d) Inflamed skin

B.

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) Look and observe before touching the client. b) Use good lighting, preferably sunlight. c) Eliminate distracting noises from the environment. d) Compare appearance of symmetric body parts.

C.

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's a) lungs. b) abdomen. c) bone. d) liver.

C.

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 after touching the client b) Put on a personal protection gown c) Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface d) Disinfect the stethoscope before touching the client

D.

Which of the following techniques are used in a physical assessment? Select all that apply. a) Palpation b) Questioning c) Inspection d) Auscultation e) Subjectivity

A, C, D

Which describes the nurse using the technique of percussion? a) The nurse notes resonance over the individual's thorax. b) The nurse detects rustling over the individual's thorax. c) The nurse notes symmetry of the individual's thorax. d) The nurse detects crepitus over the individual's thorax.

A.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? a) Tuning fork b) Coin or key c) Reflex hammer d) Tongue depressor

B.

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. a) Gloves b) Nasopharyngeal airway c) Face shield d) Stethoscope e) Gown

A, C, E

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? a) Skin lesion size b) Mid-arm circumference c) Pupillary size d) Client's height

A.

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? a) Knee-chest b) Dorsal recumbent c) Supine d) Prone

A.

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond? a) Ask the physician to perform the examination b) Explain the importance of the examination and the risks of breast cancer c) Insist that the client undress and allow her breasts to be examined, for her own good d) Comply with the client's request and proceed with the rest of the examination

B.

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? a) Gloves, gown b) Gloves, mask, protective eye goggles, gown c) Mask, protective eye goggles d) Mask, protective eye goggles, gown

B.

The nurse is planning to assess for the presence of lower pitch sounds when examining a patient's heart. Which item of equipment would the nurse use to make this assessment? a) Tuning fork b) Bell of a stethoscope c) Diaphragm of a stethoscope d) Two test tubes

B.

When performing a physical examination of an older adult client, which of the following would be most appropriate? a) Dim the room light. b) Try to minimize position changes. c) Allow client to remain dressed. d) Omit intrusive parts of the exam.

B.

A nurse needs to auscultate the heart sounds of a patient 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) Ask the client to play some music from his laptop computer instead of watching TV. b) 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. d) Leave the television as is, as the client is enjoying his show and being distracted from his pain.

C.

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? a) Flexible metric measuring tape b) Reflex hammer c) Goniometer d) Skinfold calipers

C.

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? a) Breath b) Bowel c) Heart murmur d) Normal heart

C.

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) Explaining why standard precautions are being used b) Arranging exam equipment on a bedside tray table c) Ensuring client's privacy by providing an examination gown d) Providing a comfortable, warm room temperature

C.

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) very deep palpation. c) deep palpation. d) moderate palpation.

C.

The nurse is applying standard precautions by performing which of the following? a) Washes the hands between examination of each body part b) Wears gown, gloves, and mask during the physical exam c) Wears gloves to palpate the tongue and buccal membranes d) Discards in the trash can the safety pin that was used to assess sensory perception

C.

A nurse recognizes that it is best to begin the objective data collection with which procedure? a) Begin at the head and move in a systematic approach b) Auscultation of all necessary body systems to prevent disturbing any organs c) Allow the client to undress and put on a gown d) Measure the client's vital signs, height, and weight

D.

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? a) Inspection, auscultation, percussion, palpation b) Auscultation, percussion, palpation, inspection c) Percussion, palpation, inspection, auscultation d) Inspection, palpation, percussion, auscultation

D.

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation? a) Application of firm pressure when using the bell b) Use the bell to detect high-pitched sounds c) Use the diaphragm to listen to low-pitched sounds d) Ensure that contact with the skin is maintained

D.