Chapter 3

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 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. (less)

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 goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee. Skinfold calipers are used to measure skinfold thickness of subcutaneous tissue. A flexible metric measuring tape may be used for many purposes, including measuring the size of extremities. (less)

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

Lungs To assess the patient's breathing sounds, the nurse auscultates the lungs using the stethoscope.

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene Respiratory hygiene/cough etiquette is another area that the CDC is addressing. Patients and other people with symptoms of a respiratory infection are asked to cover their mouths and noses with a tissue when coughing or sneezing. (less)

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?

Skin lesion size A centimeter scale rule most likely would be used to measure the size of a skin lesion. A flexible tape measure would be appropriate to measure mid-arm circumference. A vertical scale in inches or meters would be appropriate to measure a client's height. Pupil size is measured in millimeters. (less)

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. 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. (less)

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

bone Flatness is a sound heard over very dense tissue like bone.

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 Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.

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. - Wash hands. -Identify ways to ensure patient privacy. Prior to conducting a physical examination of a patient, the nurse should obtain and check needed equipment, identify how to maintain patient privacy during the examination, and wash hands before beginning the examination. Having any additional noise in the background will make it difficult to obtain an accurate assessment. All environmental noise should be removed as much as possible. Good lighting is needed to ensure an accurate assessment. Dim lights can prevent getting a good visual of the area being assessed. (less)

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 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.

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 information?

Dorsal hand surface The dorsal or back surface of the hand is most sensitive to temperature and should be used to assess the temperature of the feet of an older adult client with diabetes. The finger pads are sensitive to fine discriminations, pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is sensitive to vibrations, thrills, and fremitus. (less)

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The fingerpads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus. (less)

What guidelines should the nurse keep in mind while performing auscultation?

Eliminate distracting noise from the environment The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noise from the environment to ensure that the sounds that are heard are those of the client and not the environment. Using good lighting, preferably sunlight, looking and observing before touching the client, and comparing the appearance of symmetric body parts, are some of the guidelines to perform the technique of inspection. (less)

A nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight It is important to begin the assessment with less intrusive procedures such as vital signs and height & weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed. (less)

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

Ophthalmoscope An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses. (less)

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the patient's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling. (less)

The nurse is preparing to perform a physical examination on a client. The nurse would begin with which of the following examinations?

Vital signs The nurse should begin the examination with the less intrusive procedures, such as vital signs, first. Doing so allows the client to feel more comfortable with the nurse and help to ease client anxiety about the examination. (less)

The nurse is applying standard precautions by performing which of the following?

Washes the hands between examination of each body part When adhering to standard precautions, the nurse would wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Safety pin should be disposed of in the sharps container. Gowns and masks are appropriate only if anticipated patient interaction indicates that contact with blood or body fluids may occur. (less)

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?

Wearing gloves to palpate the tongue and buccal membranes When adhering to standard precautions, the nurse would wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Safety pins should be disposed of in the sharps container. Gowns and masks are appropriate only if anticipated patient interaction indicates that contact with blood or body fluids may occur. Hand hygiene need not be performed between assessments of each system or body part. (less)

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. 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.

While performing a physical examination on an older adult, the nurse should plan to

use minimal position changes. Some positions may be very difficult or impossible for the older client to assume or maintain because of decreased joint mobility and flexibility. Therefore, try to perform the examination in a manner that minimizes position changes. (less)

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 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. (less)

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, non-intact 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 antiseptic handrub The nurse could apply an antiseptic handrub 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, non-intact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap. (less)

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens Universal precautions are a set of guidelines designed to prevent transmission of HIV, hepatitis B virus, and other blood-borne pathogens when providing fi rst aid or health care.

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained 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. (less)

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 The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client lying on her back with the hips at the edge of the examination table and the feet supported by stirrups. 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 standing position, the client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. 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. (less)

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 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, drumlike sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thudlike sound that is percussed over solid tissue such as the liver. (less)

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 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. (less)

A group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following?

The bell of the stethoscope can detect bowel sounds. The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing.

A group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following?

The diaphragm should be held firmly against the body part. The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing. (less)

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. 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.