NUR 3065 - PrepU Chapter 6
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? Femoral pulses Heart sounds Breath sounds Bowel sounds
Heart sounds Explanation: The bell of the stethoscope is used to listen to low-pitched sounds such as abnormal heart sounds (heart murmurs) and bruits. The diaphragm is used to listen for high-pitched sounds such as normal heart sounds, breath sounds, bowel sounds, and pulses.
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? Auscultation, percussion, palpation, inspection Inspection, auscultation, percussion, palpation Inspection, palpation, percussion, auscultation Percussion, palpation, inspection, auscultation
Inspection, palpation, percussion, auscultation Explanation: Inspection is the first physical assessment technique that a nurse should implement. This prevents altering the appearance of structures that may distract the nurse from completing a focused observation.
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? Light palpation Bimanual palpation Moderate palpation Deep palpation
Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.
A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement? Pupillary size Client's height Skin lesion size Mid-arm circumference
Skin lesion size Explanation: A centimeter scale rule most likely would be used to measure the size of a skin lesion. A flexible tape measure would be appropriate to measure mid-arm circumference. A vertical scale in inches or meters would be appropriate to measure a client's height. Pupil size is measured in millimeters.
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 Cover card Ophthalmoscope Rosenbaum pocket screener
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. A cover card is used to test for strabismus. A newspaper or Rosenbaum pocket screener is used to test near vision.
Which describes the nurse using the technique of percussion? The nurse detects rustling over the individual's thorax. The nurse detects crepitus over the individual's thorax. The nurse notes resonance over the individual's thorax. The nurse notes symmetry of the individual's thorax.
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 client'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.
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 To determine tenderness, moisture, and the surface skin texture To observe for abnormalities on the skin's surface To feel for deep organs or structures covered by thick muscles
To determine whether a structure is filled with air or fluid or is a solid structure Explanation: The nurse uses the percussion technique while performing a physical examination to determine whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is used to feel deep organs or structures covered by thick muscles and to determine tenderness, moisture, and surface skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface.
What is the nurse's primary role in subjective data collection? To identify needs To improve the client's health status To diagnose illness To determine health risks
To improve the client's health status Explanation: The nurse's role in subjective data collection is to gather information to improve the client's health status and to help determine the cause of the client's current symptoms. The identification of needs and risks are part of the assessment. Nurses do not diagnose illnesses.
It is recommended that a left-handed examiner adopt a right-sided position. True False
True
The nurse is caring for the client who is receiving heparin. The nurse plans to: Recap the needle after administering heparin to the client Wear a mask when administering heparin to the client Wear clean gloves when administering heparin to the client Perform hand hygiene with alcohol-based gel after administering the heparin
Wear clean gloves when administering heparin to the client Explanation: Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.
A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action? Wearing gloves to palpate the tongue and buccal membranes Performing hand hygiene between examinations of each body part Wearing a gown, gloves, and mask during the physical exam Discarding in the trash can the safety pin that was used to assess sensory perception
Wearing gloves to palpate the tongue and buccal membranes Explanation: When adhering to standard precautions, the nurse would wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a client incontinent of stool or urine) could occur. Safety pins should be disposed of in the sharps container. Gowns and masks are appropriate only if anticipated client interaction indicates that contact with blood or body fluids may occur. Hand hygiene need not be performed between assessments of each system or body part.
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. moderate palpation. light palpation. very deep palpation.
deep palpation. Explanation: Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.
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? scoliometer penlight pulse oximeter reflex hammer
reflex hammer Explanation: A reflex is used to assess deep tendon reflexes which are under the control of the neurologic system. A penlight is used to assess pupillary reflexes and aids with tangential lighting. A scoliometer measures the degree of spinal curvature. A pulse oximeter measures oxygen level.
A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? Fungus Blood Bacteria Parasites
Blood Explanation: After an anal exam, fecal material is tested for the presence of blood. Testing for other organisms requires specialized specimen collection.
Universal precautions are primarily designed to protect the health care worker from what? STDs Blood-borne pathogens Respiratory diseases Musculoskeletal injuries
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.
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? Determine tenderness, moisture, and the surface of skin texture Observe for abnormalities on the skin's surface Determine if a structure is filled with air or fluid or is a solid structure Feel for deep organs or structures covered by thick muscles
Determine if a structure is filled with air or fluid or is a solid structure Explanation: The nurse uses the percussion technique while performing a physical examination in order to determine whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is used to feel deep organs or structures covered by thick muscles, and to determine tenderness, moisture, and surface of skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface.
A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate? Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. Proceed with the pelvic exam and document the client's protests in the health record. Tell the client that this is the only way she can be checked for cancer. Ask the client if she would prefer another practitioner to perform the exam.
Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. Explanation: The nurse should explain to the client the importance of the examination and the risk of missing important information if any part is omitted. However, whether or not to have the examination is the client's decision and must be respected.
When assessing a client, the first skill used is inspection. What purpose does inspection serve? Gathering information Observing modesty Identifying internal abnormalities Feeling abnormalities
Gathering information Explanation: Inspection is the first technique of the overall general survey and for each body part, because it provides so much general information. Inspection is the one technique that is performed for every body part and body system. During inspection, the nurse does not use the hands to feel anything. Inspection is not to observe the client's modesty or to identify anything internal. Feeling some abnormalities and identifying some internal abnormalities would not be inspection but rather palpation. Inspection does not help with observing modesty.
You have finished the physical examination. What do you do immediately after finishing? (Mark all that apply.) Give your general impressions Perform interventions Share findings with physician Identify needed laboratory tests Tell client what to expect next
Give your general impressions Tell client what to expect next Explanation: When you have completed the examination, tell the client your general impressions and what to expect next.Give your general impressions Tell client what to expect next Explanation: When you have completed the examination, tell the client your general impressions and what to expect next.
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? Mask, protective eye goggles Mask, protective eye goggles, gown Gloves, mask, protective eye goggles, gown Gloves, gown
Gloves, mask, protective eye goggles, gown Explanation: Because this client has emphysema with a chronic productive cough, it is likely that the nurse will not only come into direct contact with the client's sputum or mucus (a body fluid) during examination of his oral cavity, which requires the use of gloves, but also that sputum will be sprayed on the nurse's face and body, which requires the use of a mask, protective eye goggles, and a gown.
