Nursing Health Assessment- PrepU ch3

light

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?

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?

alcohol-based rub

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

blanket

When performing a physical assessment on an older adult client, what should the nurse consider offering this client?

The nurse detects resonance over the individual's thorax.

Which describes the nurse using the technique of percussion?

bone

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

mouth, nose, eye protection gloves gown

examples of personal protective equipment

The diaphragm should be held firmly against the body part.

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

peripheral vascular

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

nurse detects an odor of the patient's breath

Which illustrates the nurse using the technique of inspection?

low frequency

You should use the bell of the stethoscope when auscultating what type of sounds?

palpatation

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

snellen chart

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?

adequate lighting

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?

wood's light

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?

resonance

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?

prone

A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination?

light palpation

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

application of an antiseptic handrub

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?

deep palpation

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

heart sounds

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?

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

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?

Hyperresonance

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

palpatation

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?

otoscope

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?

Bell of stethoscope

The nurse is planning to assess for the presence of lower pitch sounds when examining a patient's heart. Which item of equipment would the nurse use to make this assessment?

ensure contact with skin is maintained

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

improve clients health status

What is the nurse's primary role in subjective data collection?

blunt percussion

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

skinfold calipers

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?

rub the hands and fingers until dry

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?

minimize position changes

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate?

hyperresonant

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?

eliminate distracting noise from environment

What guidelines should the nurse keep in mind while performing auscultation? (stethoscope)