Ch 3 Collecting objective data

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 nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

What can the nurse assess using percussion?

boarders of the heart

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

complete the forgotten portion of the exam out of sequence

A nurse on an oncology unit enters a client's room to auscultate bowl sounds. What should the nurse do before auscultating?

disinfect the stethoscope before touching the client

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

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

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

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

resonance

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

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

bone

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

dorsal surface

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

examining the tongue

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

When assessing pulses, the nurse would use which part of the hand for palpation?

finger pads

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, gown, protective eye goggles, gown

What included in personal protective equipment? Select all that apply.

gown, gloves, mouth, nose, eye protection

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

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

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

palpation

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 sounds

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

strength of reflex

Which illustrates the nurse using the technique of inspection?

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

Which describes the nurse using the technique of percussion?

the nurse notes resonance over the individual's thorax

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

up and back

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

hand hygiene

Which describes the nurse using the technique of auscultation?

the nurse detects gurgling throughout the abdomen

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

wearing gloves when palpating the tongue, lips, and gums