Weber Chapter 3

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

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

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

Turn down the volume if the television or radio is on.

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

Tympany

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 client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?

auscultation

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

balance

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

bone

Light palpation is most appropriate to assess the

inflamed areas of skin

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

inspection

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

lungs

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?

otoscope

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

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

Blood-borne pathogens

What can the nurse assess using percussion?

Borders of the heart

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

Dorsal surface

The nurse is conducting a physical examination of a client 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 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

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.

Gloves Gown Face shield

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

Hearing loss

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

Inspection Palpation Auscultation

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

Light palpation

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

Low-frequency sounds

The admitting nurse has just met a new client. As the nurse introduces himself, he begins the process of inspection on this client. 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 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

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?

Skinfold calipers

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

Strength of a reflex

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

Which illustrates the nurse using the technique of inspection?

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

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client?

handwashing

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

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 nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

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

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.

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

Ophthalmoscope

Purposeful hourly rounding by the nurse should include which assessments? (Select all that apply.)

Pain Personal needs Position

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.

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 ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c d e b a

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?

inspection

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.