jensen chapter 3

What assessment technique is performed for every body part and body system? -Auscultation -Inspection -Palpation -Percussion

inspection

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using -inspection. -palpation. -Doppler magnification. -percussion.

percussion

What would be the expected tone elicited by percussion of a normal lung? -Resonance -Hyper-resonance -Tympany -Dullness

resonance

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? -Flatness -Resonance -Tympany -Dullness

resonance

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 patient. The nurse should be aware of what risk when using this assessment technique? -Risk for injury -Risk for infection -Risk for chronic pain -Risk for impaired skin integrity

risk for injury

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

The nurse is assessing a client. Which body area will the nurse use the diaphragm of the stethoscope to assess? Select all that apply. -Bruits -Heart sounds -Breath sounds -Bowel sounds -Heart murmurs

-bowel sounds -heart sounds -breath sounds

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last. 1 Wet the hands. 2 Apply soap. 3 Scrub the hands together vigorously for 15 seconds. 4 Rinse the hands. 6 Turn off faucet with paper towel. 5 Dry hands

1.Wet the hands. 2.Apply soap. 3.Scrub the hands together vigorously for 15 seconds. 4.Rinse the hands. 5.Dry hands 6.Turn off faucet with paper towel.

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? -Auscultation, percussion, palpation, inspection -Percussion, palpation, inspection, auscultation -Palpation, inspection, auscultation, percussion -Inspection, palpation, percussion, auscultation

Inspection, palpation, percussion, auscultation

Which measure does the nurse take to prevent transmission of organisms? -Uses clear polish on artificial nails. -Uses alcohol-based hand gel for visibly soiled hands. -Vigorously scrubs hands together for 30 seconds. -Maintains fingernails to ¼ inch or shorter.

Maintains fingernails to ¼ inch or shorter.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? -Tuning fork -Otoscope -Penlight -Ophthalmoscope

Ophthalmoscope

When should the nurse perform hand washing? Select all that apply. -When hands are visibly soiled -After removing gloves -After providing mouth care -After reconciling the patient's medications -After taking the blood pressure of a patient with intact skin

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

An instructor is explaining the technique for deep palpation, describing it as which of the following? -Using both hands to depress the skin one-half of an inch -Using the dominant hand to depress the skin one-half to three-quarters of an inch -Using both hands to depress the skin 1 to 2 inches -Using one hand and depressing the skin 1 centimeter

Using both hands to depress the skin 1 to 2 inches

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

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

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? -Nonantimicrobial soap and water with friction -Hand wash with antiseptic soap -Application of an antiseptic handrub -No washing is needed because hands are not soiled

application of an antiseptic handrub

A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this patient's anxiety? -Have him urinate before the examination. -Perform the genital assessment first to get it over with. -Before performing each procedure, explain what it involves and its purpose. -Have him undress and put on an examination gown.

before performing each procedure, explain what it involves and its purpose

Universal precautions are primarily designed to protect the health care worker from what? -STDs -Musculoskeletal injuries -Blood-borne pathogens -Respiratory diseases

blood-borne pathogens

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

What can the nurse assess using percussion? -Borders of the heart -Movement of the diaphragm during expiration -Strength of the pulse -Rectal distension

borders of the heart

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

A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam? -Explain the purpose of the interview to the client. -Construct the client's family genogram. -Establish the client's reliability as historian. -Collect necessary equipment essential to the exam.

collect necessary equipment essential to the exam

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 -light palpation. -moderate palpation. -deep palpation. -very deep palpation.

deep palpation

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment? -Feel for deep organs or structures covered by thick muscles -Determine tenderness, moisture, and the surface of skin texture -Determine if a structure is filled with air or fluid or is a solid structure -Observe for abnormalities on the skin's surface

determine if a structure is filled with air or fluid or is a solid structure

The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds. -True -False

false

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? -Parasitic infection -Fungal infection -Bacterial infection -Allergic reaction

fungal infection

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? -Resonant -Tympanic -Hyperresonant -Flat

hyperresonant

Light palpation is most appropriate to assess the -appendix -bladder -inflamed areas of skin -liver

inflamed areas of skin

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? -Inspection -Palpation -Percussion -Auscultation

inspection

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

palpation

For which assessment would the nurse plan to use light palpation? -Papular rash -Shape of abdominal mass -Size of liver -Pulsation of abdominal aorta

papular rash

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection? -Gather as much general information as possible -Pay attention to the details while observing -Write down as many details as possible during the observation -Not to let the patient know he is being observed

pay attention to the details while observing

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

the nurse detects a fruity odor of the patients breath

A nurse performing percussion over the area of the stomach should anticipate hearing which type of sound? -Tympany -Dullness -Resonance -Hyper-resonance

tympany

The nurse would use what part of the hand when assessing temperature during palpation? -Dorsal surface -Fingerpads -Ulnar surface -Palmar surface

dorsal surface

When assessing pulses, the nurse would use which part of the hand for palpation? -Fingerpads -Ulnar surface -Palmar surface -Dorsal surface

finger pads

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? -respiratory -genitourinary -gastrointestinal -peripheral vascular

peripheral vascular

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

-gloves -gown -mouth, nose, eye protection

For which assessment would the nurse plan to use indirect percussion? Select all that apply. -Kidneys -Newborn thorax -Gallbladder -Sinuses -Liver

kidneys liver gallbladder

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

kness-chest

The nurse is preparing to assess an older adult client's near vision. The nurse would use which piece of equipment for the assessment? -Newspaper -Snellen chart -Ophthalmoscope -Penlight

newspaper

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact? -penlight -scoliometer -reflex hammer -pulse oximeter

reflex hammer

The ulnar edge of the hand is highly receptive to which of the following sensations? -Moisture and contour -Vibrations and moisture -Contour and temperature -Temperature and vibrations

temperature and vibrations

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 detects rustling over the individuals thorax

The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique? -Make a fist with one hand -Tap directly over the lung tissue -Place one hand flat on the body area -Use the middle finger to deliver two taps

use the middle finger to deliver two taps

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 -Penlight -Magnifying glass -Examination light

woods light

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? -Application of firm pressure when using the bell -Using the diaphragm to listen to low-pitched sounds -Using the bell to detect high-pitched sounds -Ensuring that contact with the skin is maintained

ensuring that contact with the skin is maintained

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system? -palpation -inspection -percussion -auscultation

inspection

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

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? -Light palpation -Moderate palpation -Deep palpation -Bimanual palpation

light palpation

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

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this? -Stethoscope -Otoscope -Ophthalmoscope -Sphygmomanometer

otoscope

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

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 patient. The nurse should be aware of what risk when using this assessment technique? -Risk for infection -Risk for chronic pain -Risk for injury -Risk for impaired skin integrity

risk for injury

Which describes the nurse using the technique of palpation? -The nurse notes increased warmth surrounding an abdominal incision. -The nurse notes asymmetry of the individual's abdomen. -The nurse notes gurgling sounds over the individual's abdomen. -The nurse notes tympany over the individual's lower abdomen.

the nurse notes increased warmth surrounding an abdominal incision

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation? -Intestines -Muscles -Thyroid gland -Pancreas

thyroid gland

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound? -Resonance -Hyper-resonance -Tympany -Dullness

tympany

Which is an example of percussion? Select all that apply. -The nurse notes dullness over the patient's liver. -The nurse notes rustling over the patient's thorax. -The nurse notes gurgling throughout the patient's abdomen. -The nurse notes tympany over the patient's lower abdomen. -The nurse notes resonance over the patient's thorax.

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 palpation? -The nurse notes asymmetry of the individual's abdomen. -The nurse notes gurgling sounds over the individual's abdomen. -The nurse notes tympany over the individual's lower abdomen. -The nurse notes increased warmth surrounding an abdominal incision.

The nurse notes increased warmth surrounding an abdominal incision.

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? -Reflex hammer -Skinfold calipers -Flexible metric measuring tape -Goniometer

goniometer

You should use the bell of the stethoscope when auscultating what type of sounds? -Abnormal sounds -High-frequency sounds -Low-frequency sounds -Sounds that are partially audible without a stethoscope

low frequence sounds

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment? -Doppler -stethoscope bell -sphygmomanometer -stethoscope diaphragm

stethoscope bell

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 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

Disinfect the stethoscope before touching the client

Which of the following statements is true of the role of inspection in the physical examination? -It should be performed after auscultation but before palpation and percussion. -It is often the source of the most physical signs. -To maximize findings, local inspection should be conducted prior to general inspection. -The acuity of the client will determine whether general or local inspection should be implemented in the examination.

It is often the source of the most physical signs.

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area? -percussion -auscultation -light palpation -deep palpation

ausculation

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? -Finger pad surface -Palmar hand surface -Dorsal hand surface -Ulnar hand surface

dorsal hand surface

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

dorsal surface

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action? -Depressing the skin 1 to 2 centimeters with the dominant hand -Feeling the surface structures using a circular motion -Placing the nondominant hand on top of the dominant hand -Using one hand to apply pressure and the other hand to feel the structure

feeling the surface structures using a circular motion

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? -Bowel sounds -Breath sounds -Heart sounds -Femoral pulses

heart sounds

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

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. -Begin at the head and move in a systematic approach. -Auscultate all necessary body systems to prevent disturbing any organs. -Allow the client to undress and put on a gown.

measure the clients vital signs, height, and weight

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case? -Fingertips -Palmar surface -Dorsal surface -Fingerpads

palmar surface

hile performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using -inspection. -palpation. -Doppler magnification. -percussion.

percussion

The nurse wears gloves to: -Prevent transmission of flora from patient to patient. -Increase the risk of the nurse acquiring infection from the patient. -Limit exposure to body fluids and secretions. -Facilitate contamination of the hands of the nurse.

prevent transmission of flora from patient to patient

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment? -Supine -Prone -Knee-chest -Lithotomy

prone

The nurse is using the fingerpads of the hand to palpate a body part. The nurse would best be able to detect which finding? -Temperature -Vibrations -Pulses -Fremitus

pulses

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub? -Rub the hands and fingers until dry -Rub only the palms of the hands -Use when the hands are visibly soiled -Dry the hands on available paper towels

rub the hands and fingers until dry

The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain? -Penlight -Tongue depressor -Tuning fork -Otoscope

tuning fork

Which is an example of palpation? Select all that apply. -The nurse detects a small mass in the epigastric area. -The nurse detects crepitus over the individual's thorax. -The nurse detects increased warmth surrounding an abdominal incision. -The nurse detects fruity odor of the patient's breath. -The nurse detects dullness over the liver.

-The nurse detects a small mass in the epigastric area. -The nurse detects crepitus over the individual's thorax. -The nurse detects increased warmth surrounding an abdominal incision.

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? -Bowel sounds -Breath sounds -Femoral pulses -Heart sounds

heart sounds

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

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding? -Inform the client that the lump may be malignant. -Discuss treatment options with the client. -Consult with a clinical instructor. -Ask another student nurse to confirm the finding.

consult with a clinical instructor

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use? -direct palpation -direct percussion -indirect palpation -indirect percussion

indirect percussion

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? -Percuss the region before auscultating. -Palpate the region before auscultating. -Assist the client to a sitting position. -Reduce all environmental noise.

reduce all environmental noise

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? -Platform scale with height attachment -Metric ruler -Sphygmomanometer -Skinfold calipers

skinfold calipers

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? -One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. -The middle finger of one hand is placed on the body surface and the other middle finger strikes. -The ulnar surface of one hand is placed against the body surface and vibrations are felt. -One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.

the middle finger of one hand is placed on the body surface and the other middle finger strikes

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? -Prone -Supine -Knee-chest -Dorsal recumbent

Knee-chest

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 -Gloves, gown -Mask, protective eye goggles, gown -Mask, protective eye goggles

gloves, mask, protective eye goggles, gown

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility? -speculum -test tubes -goniometer -stadiometer

goniometer