Chapter 3: Collecting Objective Data: The Physical Examination

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? Cervical spine Thorax Axillary nodes Balance

Balance Chapter 3: Collecting Objective Data: The Physical Examination - Page 35

A nurse is preparing to evaluate an older 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? Snellen E chart Braden scale Penlight Reflex (percussion) hammer

Braden scale Chapter 3: Collecting Objective Data: The Physical Examination - Page 30

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

Coin or key Chapter 3: Collecting Objective Data: The Physical Examination - Page 31

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. Perform the complete assessment at the end of the shift. Inform the client that the examination was incomplete and start over. Proceed as normal with the assessment data collected from the incomplete exam.

Complete the forgotten portion of the exam out of sequence. Chapter 3: Collecting Objective Data: The Physical Examination - Page 33

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

Disinfect the stethoscope before touching the client Chapter 3: Collecting Objective Data: The Physical Examination - Page 40

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? Finger pads Ulnar surface Palmar surface Dorsal surface

Dorsal surface Chapter 3: Collecting Objective Data: The Physical Examination - Page 37

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? Range of motion of the spine Posterior chest excursion Head and neck range of motion Dorsiflexion of the foot

Dorsiflexion of the foot Chapter 3: Collecting Objective Data: The Physical Examination - Page 34

A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse? Inform the client that an assessment must be completed in order to provide treatment. Tell the client she may have a friend or family member stay with her during the assessment. Explain to the client why the assessment is important and the possibility of missing important findings. Respect the client's decision and do not press her on the issue.

Explain to the client why the assessment is important and the possibility of missing important findings. Chapter 3: Collecting Objective Data: The Physical Examination - Page 33

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.. Nasopharyngeal airway Gloves Gown Face shield Stethoscope

Gloves Gown Face shield Chapter 3: Collecting Objective Data: The Physical Examination - Page 33

What included in personal protective equipment? Select all that apply. Gloves Gown Mouth, nose, eye protection Special linen Cleaning processes

Gloves Gown Mouth, nose, eye protection Chapter 3: Collecting Objective Data: The Physical Examination - Page 32

The nurse would use the tuning fork to assess for what? Hearing loss Eye movement Visualization Reflexes

Hearing loss Chapter 3: Collecting Objective Data: The Physical Examination - Page 30-31

The nurse is performing a physical assessment. The nurse does what first? Auscultation Inspection Palpation Percussion

Inspection Chapter 3: Collecting Objective Data: The Physical Examination - Page 36-37

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

Inspection Palpation Auscultation Chapter 3: Collecting Objective Data: The Physical Examination - Page 36

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 Intermediate Moderate Deep

Light Chapter 3: Collecting Objective Data: The Physical Examination - Page 37

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? Supine Lithotomy Standing Prone

Lithotomy Chapter 3: Collecting Objective Data: The Physical Examination - Page 36

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? Inspection Palpation Percussion Auscultation

Palpation Chapter 3: Collecting Objective Data: The Physical Examination - Page 37

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? Platform scale with height attachment Metric ruler Sphygmomanometer Skinfold calipers

Skinfold calipers Chapter 3: Collecting Objective Data: The Physical Examination - Page 30

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 Ophthalmoscope Opaque card Penlight

Snellen chart Chapter 3: Collecting Objective Data: The Physical Examination - Page 30

Which describes the nurse using the technique of auscultation? The nurse detects gurgling throughout the abdomen. The nurse detects foul odor of the urine. The nurse notes a small nodule in the breast. The nurse notes dullness over the liver.

The nurse detects gurgling throughout the abdomen. Chapter 3: Collecting Objective Data: The Physical Examination - Page 39

Which is an example of inspection? Select all that apply. The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine. The nurse detects a small mass in the epigastric area. The nurse notes crackling over the individual's thorax.

The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine. Chapter 3: Collecting Objective Data: The Physical Examination - Page 37

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

The nurse notes resonance over the individual's thorax. Chapter 3: Collecting Objective Data: The Physical Examination - Page 39

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. Turn down the lights in the room. Ensure that the client is lying down. Ask the client to take deep breaths.

Turn down the volume if the television or radio is on. Chapter 3: Collecting Objective Data: The Physical Examination - Page 31

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? After the physical examination is completed When the demographic data has been documented Upon meeting the client and family members As soon as any visitors have left the room

Upon meeting the client and family members Chapter 3: Collecting Objective Data: The Physical Examination - Page 33

Which action by a nurse demonstrates the correct application of the principles of standard precautions? Using an antiseptic hand scrub to cleanse visibly soiled hands. Wearing a gown, gloves, and mask for the physical exam Wearing gloves when palpating the tongue, lips, & gums Change gloves after each body area is examined

Wearing gloves when palpating the tongue, lips, & gums Chapter 3: Collecting Objective Data: The Physical Examination - Page 32

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

bone. Chapter 3: Collecting Objective Data: The Physical Examination - Page 39

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 d, b, a, e, c a, c, b, d, e c, e, b, d, a d, e, b, a, c

c, d, e, b, a Chapter 3: Collecting Objective Data: The Physical Examination - Page 39

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? pad the table use as a drape collect body fluids serve as a head support

use as a drape Chapter 3: Collecting Objective Data: The Physical Examination - Page 36

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client? "It's a policy I have to follow." "They help me feel your body parts under your skin better." "They make sure that any microorganisms on my hands do not touch your skin." "Since we don't know what's wrong with you, I wear gloves to make sure I don't get sick."

"They make sure that any microorganisms on my hands do not touch your skin." Chapter 3: Collecting Objective Data: The Physical Examination - Page 32

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? Warm, comfortable room Quiet area free of disturbance Adequate lighting Firm examination bed or table

Adequate lighting Chapter 3: Collecting Objective Data: The Physical Examination - Page 31

What is used to gauge central and peripheral nervous system disorders? Strength of a reflex Gait Tuning fork Heat and cold

Strength of a reflex Chapter 3: Collecting Objective Data: The Physical Examination - Page 30

Which illustrates the nurse using the technique of inspection? The nurse detects a fruity odor of the client's breath. The nurse notes increased warmth surrounding the client's incision. The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse detects tympany over the client's lower abdomen.

The nurse detects a fruity odor of the client's breath. Chapter 3: Collecting Objective Data: The Physical Examination - Page 37

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 firm percussion. direct percussion. indirect percussion. blunt percussion.

blunt percussion. Chapter 3: Collecting Objective Data: The Physical Examination - Page 38

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. tympany. dullness. flatness.

hyperresonance. Chapter 3: Collecting Objective Data: The Physical Examination - Page 39

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 sphygmomanometer stethoscope ophthalmoscope

otoscope Chapter 3: Collecting Objective Data: The Physical Examination - Page 30

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? Nonantimicrobial soap and water with friction Hand wash with antiseptic soap Application of an alcohol-based hand rub No washing is needed because hands are not soiled.

Application of an alcohol-based hand rub Chapter 3: Collecting Objective Data: The Physical Examination - Page 32

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 Prone Supine Dorsal recumbent

Knee-chest Chapter 3: Collecting Objective Data: The Physical Examination - Page 36

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? Hyper-resonance Resonance Tympany Dullness

Resonance Chapter 3: Collecting Objective Data: The Physical Examination - Page 39