Chapter 3: Collecting Objective Data: The Physical Examination PrepU Quiz and answers

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?

The nurse can apply an antiseptic hand rub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

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

The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the patient in the seated position. The thorax is assessed in either the sitting or lying position.

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

bone. Flatness is a sound heard over very dense tissue like bone.

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

hyper-resonance. Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.

Light palpation is most appropriate to assess the

inflamed areas of skin Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).

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.

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

Strength of a reflex

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

The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment

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 To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A penlight is used to test pupillary constriction.

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, mask, protective eye goggles, gown Because this client has emphysema with a chronic productive cough, it is likely that the nurse will not only come into direct contact with the client's sputum or mucus (a body fluid) during examination of his oral cavity, which requires the use of gloves, but also that sputum will be sprayed on the nurse&'s face and body, which requires the use of a mask, protective eye goggles, and a gown.

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 The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds.

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?

Inspection, palpation, percussion, auscultation Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected. For abdomen it is: inspection, auscultation, percussion, and palpate

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 injury

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

The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens.

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

Dorsal surface The dorsal surface is used for temperature. The fingerpads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus.

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. t is important to begin the assessment with less intrusive procedures such as vital signs and height and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed.

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 Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drumlike sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thudlike sound that is percussed over solid tissue such as the liver.

client who reports having a burning rash in the perianal area says, "Just stop asking questions and look at the rash right now." Which response by the nurse is best?

"I just need to gather more information about your symptoms to help you the best way I can." The collection of subjective information during history taking assists the nurse in focusing the examination accordingly. Conducting a thorough health history prior to a physical examination of the rash ensures that that nurse has not missed any clues that may uncover an underlying cause to the chief report. Looking at the rash immediately may cause the health history to be rushed and risk completing the assessment in a less thorough manner. It is within the nurse's scope of practice to assess the affected area and engage in the nursing process to manage the client's care. Both the subjective data obtained from the health history and the physical examination come together to ensure a comprehensive client assessment.

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

auscultation During the abdominal examination, the pattern will be inspection, auscultation, percussion, and palpation. Auscultation follows inspection so as not to increase bowel motility with palpation.

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

Blood-borne pathogens Universal precautions are a set of guidelines designed to prevent transmission of HIV, hepatitis B virus, and other blood-borne pathogens when providing first aid or health care.

The nurse wears gloves to:

Prevent transmission of flora from patient to patient. The nurse wears gloves to prevent transmission of flora from patient to patient, prevent exposure to body fluids and secretions, decrease the risk of the nurse acquiring infection from the patient, and reduce contamination of the hands of the nurse.

Which is an example of inspection?

The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine. Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a foul odor to the patient's urine and note rashes and symmetry of the thorax. while; The nurse uses the technique of palpation to detect masses. Auscultation is used by the nurse to assess lung sounds, such as crackling.

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 The nurse needs an otoscope to visualize the tympanic membrane and the inner ear. The nurse would need a sphygmomanometer to assess the client's blood pressure. The nurse would need a stethoscope to auscultate the lungs and abdomen. The nurse would need an opthalmoscope to visualize the retina of the eye.