Prep U CH 3

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

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

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

Auscultation Inspection Palpation

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

Balance

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

Blood-borne pathogens

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

Bone

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

You are performing a physical examination on a new patient. What would you be assessing if you were testing the patient's sense of smell?

Cranial nerves

The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching?

Dispose of tissues directly into trash cans

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment.

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

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?

Examining the tongue

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.

Face shield Gown Gloves

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

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?

Goniometer

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

The nurse would use the tuning fork to assess for what?

Hearing loss

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 Murmurs

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?

Hyperresonant

At the beginning of the shift, an older adult hospitalized for pneumonia reports shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

Immediate

When should the nurse wear gloves? Select all that apply.

In anticipation of body fluid contact When touching blood or body fluids

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

Inspection

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

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs.

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

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

Light palpation

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

Limit position changes as much as possible

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?

Lithotomy

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

Low-frequency sounds

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. Wash hands. Identify ways to ensure patient privacy.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

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?

Palmar surface

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

38s Report this Question For which assessment would the nurse plan to use light palpation?

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?

Pay attention to the details while observing

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment?

Prone

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.

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

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

For which assessment would the nurse plan to use direct percussion?

Sinuses

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

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

Which illustrates the nurse using the technique of inspection?

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

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

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.

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?

Thyroid gland

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

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

Tympany

How should the nurse place the ear of an adult when using the otoscope?

Up and back

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

Wearing gloves when palpating the tongue, lips, & gums

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

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

blunt percussion.

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.

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

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.

Light palpation is most appropriate to assess the

inflamed areas of skin

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

palpation

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion.

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

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 preparing to evaluate an elderly client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

Braden Scale

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

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

Resonance

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply.

Readjust the ear pieces to ensure a snug fit Angle the binurals towards the nose Eliminate distracting noises from the environment