Chapter 3: Collecting Objective Data: The Physical Examination

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

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

Sinuses

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

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.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion.

A nurse is preparing to conduct an assessment on a client. In what order should the nurse conduct the following actions? Place the steps in the correct order.

1. Wash hands and don gloves. 2. Take the client's vital signs. 3. Assess eyes, ears, nose, and mouth. 4. Auscultate heart and lung sounds. 5. Assess genitalia.

The nursing instructor is teaching nursing students about hand hygiene prior to performing a health assessment. The nursing instructor determines effectiveness of the teaching when the students state that hand hygiene should occur at which point? Select all that apply.

1. before touching a client 2. before eating 3. before leaving a client's room 4. when hands become visibly soiled

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

Blood-borne pathogens

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

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 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 preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment.

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

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

Examining the tongue

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

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

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

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

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

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

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.

The nurse is performing percussion over the lung fields. The nurse hears a dull tone in the lower lung fields, which is a new finding. What is the next best action of the nurse?

Notify the health care provider and prepare to transport the client for a chest x-ray.

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

Ophthalmoscope

You are performing a shift assessment as you begin caring for one of your clients. What is the most effective assessment technique for the lymph nodes of the neck?

Palpation

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

Papular rash

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

Strength of a reflex

A student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed?

The bell of the stethoscope is used to auscultate bowel sounds.

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.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

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

Turn down the volume if the television or radio is on.

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

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status?

auscultation

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

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

bone

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?

deep palpation

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

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

palpation

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 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

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

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

When is it necessary for a nurse to change gloves? Select all that apply.

1. Between tasks and procedures on the same client 2. When going from a contaminated area to a cleaner area 3. After contact with material that contains a high concentration of microorganisms

The nurse wears gloves for which of the following purposes? Select all that apply.

1. Prevent transmission of flora from client to client. 2. Limit exposure to body fluids and secretions

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 conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Complete the forgotten portion of the exam out of sequence.

A nurse in a clinic is preparing to perform an assessment of the eyes on a new client. What equipment should the nurse gather for this assessment? Select all that apply.

1. penlight 2. newspaper 3. Snellen chart

A nurse is preparing to assess a client's abdomen. Which client position would be best for this assessment?

Supine

Which is an example of inspection? Select all that apply.

1. The nurse notes a fine rash covering the individual's thorax. 2. The nurse notes symmetry of the individual's thorax. 3. The nurse detects foul odor of the urine.

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

A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?

Practice performing a physical examination on a classmate, friend, or relative.