health assessment chapter 3

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

A hyperresonant lung sound is very loud, low in pitch, long in duration, and booming in quality. This is the sound heard from emphysematous lungs.

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

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.

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

Blood-borne pathogens

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 patient 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 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

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.

Gloves Gown Face shield

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?

Gloves, mask, protective eye goggles, gown

Light palpation is most appropriate to assess the

Inflamed areas of the skin

Which of the following techniques are used in a physical assessment? Select all that apply.

Inspection Palpation Auscultation

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

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 Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate palpation is a distracter for this question.

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.

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. Identify ways to ensure patient privacy. Wash hands

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

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

A nurse is preparing 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

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

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

The nurse notes dullness over the patient's liver. The nurse notes resonance over the patient's thorax. The nurse notes tympany over the patient's lower abdomen.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound?

Tympany The stomach is air filled, and the normal sound heard over an area that is air filled is tympany.

When should the nurse perform hand washing? Select all that apply.

When hands are visibly soiled After removing gloves After providing mouth care

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.

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

bone

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

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

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

dorsal surface

While examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand

When assessing pulses, the nurse would use which part of the hand for palpation?

fingerpads

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 wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

indirect percussion

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection

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

light palpation

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 noises

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