Chapter 3: Collecting Objective Data: the Physical Examination

adequate lighting

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?

snellen chart

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 clients distant vision?

adequate lighting

a client with scabies visits the health care facility for a flow-up appointment. which preparation by the nurse is of greatest priority for the physical examination of this client?

Color

a nurse begins her examination of a client with a skin disorder by using inspection techniques. which skin characteristic can the nurse observe by using inspection?

- eliminate distracting noises from the environment -readjust the ear pieces to ensure a snug fit -angle the binaural towards the nose

a nurse experiences difficulty auscultating the heat sounds of a client. what should the nurse do to enhance the sounds of the heart tones? select all that apply

inspection, palpation, percussion, auscultation

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?

coin or key

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

gloves, mask, protective eye goggles, and gown

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?

practice performing a physical examination on a classmate, friend, or relative

a nursing student will soon be graduation and beginning a new job at a local health clinic. the nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. which of the following would be the best way for this student to gain confidence in assessment skills?

application of an alcohol-based hand rub

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, non intact skin, or wound dressings. the nurse's hands do not appear to be visibly soiled. what hand hygiene should the nurse perform?

the middle finer of one hand is placed on the body surface and the other middle finger strikes

the nurse is performing indirect percussion of the lungs on a young woman with pneumonia. which of the following is the correct hand placement for this technique?

otoscope

a nurse is examine a young boy who is complaining that he cannot hear as well out of one ear as he used to. the nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. which piece of equipment should the nurse use to do this?

ensuring that contact with the skin is maintained

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?

wood's light

a nurse is examining a client suspected of having fungal infection of the skin. which piece of equipment should the nurse use to confirm the presence of fungus?

goniometer

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?

light palpation

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

palmar surface

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?

prone

a nurse needs to assess a client's range of motion in the hip joints. which position is best to facilitate this examination?

wearing gloves when palpating the tongue, lips, & gums

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

to determine whether a structure is filled with air or fluid or is a solid structure

while performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sounds waves. what is the purpose of this method of assessment?

resonance

a nurse is perfomring percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normals lungs. which of the following describes this finding?

Tympany

a nurse is perfomring percussion over the are of a clients stomach. the nurse should anticipate hearing which type of sounds?

lithotomy

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?

before performing each, explain what involves and its purpose

a nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. which of the following should the nurse do to ease this patient's anxiety?

eliminate distracting noises from the environment

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?

measure the client's vital signs, height, and weight

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?

knee-chest position

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?

lie on the back with legs together on the examination table

a nurse need to position a client in the supine position for the physical examination. the nurse should ask the client to do which of the following?

ask the client if it would be okay to mute the volume on the TV during the assessment

a nurse needs to auscultate the heart sounds of a patient who is in a hospital room watching his favorite television show. before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment ?

light palpation

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

wash hands before examination in the examination room

a nurse os preparing to physically examine a client. which action is most important to take before beginning the examination?

heart murmur

a nurse performs an admissions 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?