Prepu ch.3

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

-Inspection -Palpation -Auscultation

Which illustrates the nurse using the technique of inspection?

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

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

Up and back

Light palpation is most appropriate to assess the

inflamed areas of skin

When conducting a health assessment, it is sometimes necessary to conduct specific physical assessments that use specialized tools. What are some of these special tools? Select all that apply.

-Ophthalmoscope -Goniometer -Skin-fold calipers

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

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

Balance

A nurse is preparing to evaluate an older 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 palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

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

Dorsal surface

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

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

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

Low-frequency sounds

As the density of tissue decreases, the percussion note becomes:

Lower pitched

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.

The nurse is performing percussion over the lung fields. The nurse hears a dull tone in the lower lung fields, which is a new finding. What is the next best action of the nurse?

Notify the health care provider and prepare to transport the client for a chest x-ray.

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

The nurse is caring for the client who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the client

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

Wearing gloves when palpating the tongue, lips, & gums

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 anklesb. Groin, hips, and kneesc. Breastsd. Chest and thoraxe. 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

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.

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

Light 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

You are performing a shift assessment as you begin caring for one of your clients. What is the most effective assessment technique for the lymph nodes of the neck?

Palpation

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

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer