Chapter 3: Collecting Objective Data: The Physical Examination PrepU

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin." explanation: One reason to wear gloves is to prevent the transmission of flora from health care workers to patients. Wearing gloves is more than just following a policy. Gloves hinder the ability to discern body parts and positions. Although the client may have a communicable illness, the nurse should not make a statement that could cause the client anxiety about being ill.

What included in personal protective equipment? Select all that apply.

-Gloves -Gown -Mouth, nose, eye protection Explanation: Personal protective equipment (PPE) includes gloves, gown, mouth, nose and eye protection. Special linen and cleaning processes are not part of PPE.

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?

Ask permission to talk to the client in front of visitors. explanation: The nurse should ask permission if visitors are present to find out whether the client wishes them to know information about his condition and treatment. The visitors do not necessarily have to leave the room. If visiting hours are not over, the nurse should not tell visitors they have to leave. Best communication practices include making eye contact with all persons the nurse is speaking to.

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

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

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 Explanation: 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.

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface Explanation: The dorsal surface is used for temperature. The fingerpads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus.

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?

Explain the importance of the examination and the risks of breast cancer Explanation: If a client requests that a certain part of the examination, such as the breast examination, not be performed, the nurse should explain the importance of the examination and the risk of missing important information if any part is omitted. Simply complying with the client's request, insisting on the examination, and asking the physician to perform it would not be appropriate actions.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise. explanation: Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. explanation: 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.

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums Explanation: The nurse should wear gloves when examining or touching any areas where there is the potential for exposure to blood or body fluids. Gloves are changed between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Wearing a gown, gloves, and mask is not necessary for the entire physical assessment. If hands are visibly soiled, the nurse should wash with soap and water.

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

balance Explanation: The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the patient in the seated position. The thorax is assessed in either the sitting or lying position.

As the density of tissue decreases, the percussion note becomes:

lower pitched explanation: Low density tissue tends to produce sound that is lower pitched, musical, loud, and longer in duration than in denser tissue.

What would be the expected tone elicited by percussion of a normal lung?

resonance explanation: Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue.

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 explanation: 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.

It is recommended that a left-handed examiner adopt a right-sided position.

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

-The nurse notes gurgling sounds over the individual's abdomen. -The nurse notes crackling over the individual's thorax. -The nurse notes a rhythmic lub-dub over the patient's anterior thorax. Explanation: Auscultation is used by the nurse to assess the lub-dub sounds of the heart, lung sounds, such as rustling, and gurgling bowel sounds. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as hyperresonance over the lungs and tympanic sounds over the bowel.

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 explanation: 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.

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation Explanation: Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.

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 Explanation: 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.

The nurse is having difficulty visualizing the apical impulse during a physical examination of the cardiovascular system. Which assessment tool is required for a more accurate assessment?

penlight Explanation: A penlight provides tangential lighting and is optimal for inspecting structures such as the jugular venous pulse, thyroid gland, and apical impulse of the heart. It casts light across body surfaces that shows contours, elevations, and depressions, whether moving or stationary, into sharper relief. Although a tape measure is required for the assessment of the cardiovascular system, it is not for visualization. A stethoscope allows the nurse to auscultate the apical impulse not visualize it. A cup of water would be required if the nurse was assessing the thyroid gland.