PrepU Chapter 3

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a 1½-inch diaphragm. 1-inch bell. 1-inch diaphragm. 15-inch flexible tubing.

1½-inch diaphragm

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

When is it necessary for a nurse to change gloves? Select all that apply.

Between tasks and procedures on the same client When going from a contaminated area to a cleaner area After contact with material that contains a high concentration of microorganisms

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

Blood-borne pathogens

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? Penlight Reflex (percussion) hammer Snellen E chart Braden scale

Braden Scale

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? Use good lighting, preferably sunlight. Look and observe before touching the client. Eliminate distracting noises from the environment. Compare appearance of symmetric body parts.

Eliminate distracting noises from the environment.

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam? Providing a comfortable, warm room temperature Explaining why standard precautions are being used Ensuring client's privacy by providing an examination gown Arranging exam equipment on a bedside tray table

Ensuring client's privacy by providing an examination gown

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? Ask the client if she would prefer another practitioner to perform 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. Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

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 Using one hand to apply pressure and the other hand to feel the structure Placing the nondominant hand on top of the dominant hand Feeling the surface structures using a circular motion

Feeling the surface structures using a circular motion

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, gown Mask, protective eye goggles Gloves, gown Gloves, mask, protective eye goggles, gown

Gloves, mask, protective eye goggles, gown

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?

Heart sounds

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population? Bunions Medication allergies Inflamed skin Latex allergy

Latex allergy

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

Low-frequency sounds

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

Low-frequency sounds

The nurse wears gloves to:

Prevent transmission of flora from patient to patient This is the most important reason for gloves

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

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 infection Risk for impaired skin integrity Risk for chronic pain Risk for injury

Risk for injury

For which of the following assessments would the nurse plan to use light palpation? Size of liver Skin temperature Shape of abdominal mass Skin texture Skin rash

Skin temperature Skin texture Skin rash

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

Temperature and vibrations

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? The diaphragm should be held firmly against the body part. Auscultation can be performed through clothing. The bell of the stethoscope can detect bowel sounds. The binaurals connect the tubing to the chest piece.

The diaphragm should be held firmly against the body part

Which illustrates the nurse using the technique of inspection? 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 notes increased warmth surrounding the patient's incision. The nurse detects tympany over the patient's lower abdomen.

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

Which is an example of percussion? Select all that apply. The nurse notes gurgling throughout the patient's abdomen. The nurse notes rustling 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.

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 increased warmth surrounding an abdominal incision.

Which describes the nurse using the technique of percussion? The nurse detects rustling over the individual's thorax. 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 notes resonance over the individual's thorax.

Which describes the nurse using the technique of percussion? The nurse detects rustling over the individual's thorax. The nurse notes symmetry of 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 resonance over the individual's thorax.

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

Tympany

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

Use the middle finger to deliver two taps

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

Using both hands to depress the skin 1 to 2 inches

The nurse is caring for the patient who is receiving heparin. The nurse plans to: Recap the needle after administering heparin to the patient Perform hand hygiene with alcohol-based gel after administering the heparin Wear a mask when administering heparin to the patient Wear clean gloves when administering heparin to the patient

Wear clean gloves when administering heparin to the patient

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 Discarding in the trash can the safety pin that was used to assess sensory perception Wearing a gown, gloves, and mask during the physical exam

Wearing gloves to palpate the tongue and buccal membranes

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

an extra blanket

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? Parasites Bacteria Blood Fungus

blood

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? Coin or key Tuning fork Tongue depressor Reflex hammer

coin or key

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

The nurse is preparing for a physical examination of a client. What should the nurse do first? Auscultation Hand hygiene Palpitation Gather equipment

hand hygiene

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

hearing loss

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

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.

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? Flat Tympanic Hyperresonant Resonant

hyperresonant

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

indirect percussion

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? Deep Light Intermediate Moderate

light

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

light palpation

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

percussion

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

percussion

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

peripheral vascular

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? reflex hammer pulse oximeter penlight scoliometer

reflex hammer

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 Supine Standing Prone

Lithotomy

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

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 Quiet area free of disturbance Firm examination bed or table Warm, comfortable room

Adequate lighting

Which skin characteristics can a nurse observe by using inspection? Elasticity Temperature Texture Color

Color

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? Bacterial infection Parasitic infection Allergic reaction Fungal infection

Fungal infection

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? Breath Normal heart Heart murmur Bowel

Heart murmur

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? Inspection, auscultation, percussion, palpation Auscultation, percussion, palpation, inspection Percussion, palpation, inspection, auscultation Inspection, palpation, percussion, auscultation

Inspection, palpation, percussion, auscultation

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

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? Percussion Inspection Palpation Auscultation

Palpation

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? Examination light Magnifying glass Penlight Wood's light

Wood's light

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing indirect percussion. blunt percussion. deep palpation. moderate palpation.

blunt percussion.

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

dorsal surface

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 Gloves Stethoscope Nasopharyngeal airway Gown

face shield gloves gown

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? Metric ruler Sphygmomanometer Platform scale with height attachment Skinfold calipers

skinfold calipers

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, pancreas, thyroid gland

thyroid gland