Chapter 3: Collecting Objective Data: The Physical Examination PrepU

When assessing pulses, the nurse would use which part of the hand for palpation? a. Finger pads b. Ulnar surface c. Palmar surface d. Dorsal surface

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

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? a. Snellen E chart b. Braden scale c. Penlight d. Reflex (percussion) hammer

b. Braden scale The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores. The Snellen E chart is used to test distant vision. The penlight is used to view the mouth and throat and to transilluminate the sinuses. The reflex (percussion) hammer is used to test tendon reflexes.

While examining a client, the nurse plans to palpate temperature of the skin by using the a. fingertips of the hand. b. ulnar surface of the hand. c. dorsal surface of the hand. d. palmar surface of the hand.

c. dorsal surface of the hand. The dorsal surface of the hand is used to palpate body temperature.

When entering a client's room, what is the nurse's first action? a. Ask the client's name and birthdate. b. Take the client's blood pressure. c. Measure the client's urine output. d. Auscultate the heart and lung sounds.

a. Ask the client's name and birthdate. The Joint Commission has set national safety interventions for hospital care. One of these interventions is to identify clients correctly using two identifiers, such as name and birthdate. Clients should be correctly identified before proceeding with any other assessments or interventions.

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. a. Nasopharyngeal airway b. Gloves c. Gown d. Face shield e. Stethoscope

b. Gloves c. Gown d. Face shield The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure.

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? a. Platform scale with height attachment b. Metric ruler c. Sphygmomanometer d. Skinfold calipers

d. Skinfold calipers Skinfold calipers measure skinfold thickness of subcutaneous tissue to aid in establishing a client's percent body fat. A platform scale with height attachment measures height and weight. A metric ruler is used to measure the size of skin lesions. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.

What would be the expected tone elicited by percussion of a normal lung? a. Resonance b. Hyper-resonance c. Tympany d. Dullness

a. Resonance Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue.

What assessment technique is performed for every body part and body system? a. Auscultation b. Inspection c. Palpation d. Percussion

b. Inspection Inspection is the one technique that is performed for every body part and body system. Other techniques are not used for every body part and system.

A nurse is examining 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? a. Stethoscope b. Otoscope c. Ophthalmoscope d. Sphygmomanometer

b. Otoscope An otoscope is a device used to view the ear canal and tympanic membrane. A stethoscope is used to auscultate breath and heart sounds in the chest. An ophthalmoscope is used to view the red reflex of the eye and to examine the retina of the eye. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.

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

c. Low-frequency sounds The bell is used with light skin contact to hear low-frequency sounds.

As the density of tissue decreases, the percussion note becomes: a. Softer b. Shorter c. Lower pitched d. Less musical

c. Lower pitched Low density tissue tends to produce sound that is lower pitched, musical, loud, and longer in duration than in denser tissue.

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for? a. Testing facial sensation b. Invoking the blink reflex c. Inverting the eyelid d. Examining the tongue

d. Examining the tongue 2 × 2 gauze pads are used during tongue examination.

You are performing a physical examination on a new client. What would you be assessing if you were testing the client's sense of smell? a. Cranial nerves b. Nose c. Upper neuron function d. Strength of nerve functioning

a. Cranial nerves If not already examined, check sense of smell, strength of the temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength of the trapezia and sternomastoid muscles.

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.) a. Shape of abdominal mass b. Size of liver c. Pulsation of abdominal aorta d. Macular rash e. Texture of a mole

a. Shape of abdominal mass b. Size of liver c. Pulsation of abdominal aorta Deep palpation is used to assess the size, shape, and consistency of abdominal organs. Light palpation is used to assess surface characteristics, such as a macular rash and texture of a mole.

It is recommended that a left-handed examiner adopt a right-sided position. a. True b. False

a. True

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what? a. Hand washing b. Alcohol-based rub c. Gloves d. Use of lotions

b. Alcohol-based rub Alcohol-based rubs are the preferred method for hand hygiene when hands are not visibly soiled. Lotions and gloves are not a form of hand hygiene.

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 a. light palpation. b. moderate palpation. c. deep palpation. d. very deep palpation.

c. deep palpation. Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

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 a. hyperresonance. b. tympany. c. dullness. d. flatness.

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

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? a. Fingertips b. Palmar surface c. Dorsal surface d. Finger pads

b. Palmar surface The ulnar-or palmar-surface is the part of the hand used to palpate vibrations. The fingertips are not used to palpate. The dorsal surface is sensitive to temperature and the finger pads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitus.

The nurse would use the tuning fork to assess for what? a. Hearing loss b. Eye movement c. Visualization d. Reflexes

a. Hearing loss The tuning fork is used to assess for hearing loss. Reflexes may be checked with a reflex hammer. An ophthalmoscope is used for the eye. An ophthalmoscope and otoscope are used for visualization.

What is used to gauge central and peripheral nervous system disorders? a. Strength of a reflex b. Gait c. Tuning fork d. Heat and cold

a. Strength of a reflex The strength of a reflex is used to gauge central and peripheral nervous system disorders.

Which of the following statements is true of the role of inspection in the physical examination? a. It should be performed after auscultation but before palpation and percussion. b. It is often the source of the most physical signs. c. To maximize findings, local inspection should be conducted prior to general inspection. d. The acuity of the client will determine whether general or local inspection should be implemented in the examination.

b. It is often the source of the most physical signs. Inspection often yields the most signs during an examination. It should begin the examination, and general inspection precedes local inspection. The two are not mutually exclusive and should both be implemented in each examination.

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? a. Bowel b. Normal heart c. Breath d. Heart murmur

d. 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 must assess a client's red reflex. Which piece of equipment will the nurse need for this? a. Ophthalmoscope b. Tuning fork c. Otoscope d. Penlight

a. Ophthalmoscope An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses.

For which assessment would the nurse plan to use direct percussion? a. Sinuses b. Kidneys c. Liver d. Gallbladder

a. Sinuses The nurse performs direct percussion by tapping the fingers directly on the client's skin, such as for assessment of the sinuses. The nurse performs indirect percussion by using the non-dominant hand as a barrier between the nurse's dominant hand and the client to assess organs, such as the gallbladder, kidneys, and liver.

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? a. Wood's light b. Penlight c. Magnifying glass d. Examination light

a. Wood's light Wood's light is a special piece of examination equipment that is used to test for fungus. A penlight is used for more general assessments, such as of the mouth and throat and to transilluminate the sinuses. A magnifying glass is used to enlarge the visibility of a lesion. An examination light is used to better illuminate the client's body as a whole to facilitate physical examination.

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs? a. Resonant b. Tympanic c. Hyperresonant d. Flat

c. Hyperresonant A hyperresonant lung sound is very loud, low in pitch, long in duration, and booming in quality. This is the sound heard from emphysematous lungs.

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

a. Hand hygiene The nurse should perform hand hygiene before beginning the physical assessment. This includes prior to gathering equipment. Auscultation and palpitation should not occur until after hand hygiene has been performed.

What physical assessment technique should a nurse use to obtain a pulse on a client? a. Light palpation b. Moderate palpation c. Deep palpation d. Bimanual palpation

a. Light palpation The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpation is used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

Which describes the nurse using the technique of palpation? a. The nurse notes increased warmth surrounding an abdominal incision. b. The nurse notes asymmetry of the individual's abdomen. c. The nurse notes gurgling sounds over the individual's abdomen. d. The nurse notes tympany over the individual's lower abdomen

a. The nurse notes increased warmth surrounding an abdominal incision. The nurse uses palpation to assess the individual through touch, such as to detect increased warmth surrounding an incision. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting the symmetry of the abdomen. Auscultation is used by the nurse to assess bowel sounds. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action? a. Politely tell the visitors to leave. b. State that the visiting hours are over. c. Ask permission to talk to the client in front of visitors. d. Make eye contact solely with the client.

c. Ask permission to talk to the client in front of visitors. The nurse should ask permission if visitors are present to find out whether the client wishes them to know information about his condition and treatment. The visitors do not necessarily have to leave the room. If visiting hours are not over, the nurse should not tell visitors they have to leave. Best communication practices include making eye contact with all persons the nurse is speaking to.

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 1. c, d, e, b, a 2. d, b, a, e, c 3. a, c, b, d, e 4. c, e, b, d, a 5. d, e, b, a, c

1. c, d, e, b, a When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

Light palpation is most appropriate to assess the a. appendix b. bladder c. inflamed areas of skin d. liver

c. 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 admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? a. After the physical examination is completed b. When the demographic data has been documented c. Upon meeting the client and family members d. As soon as any visitors have left the room

c. Upon meeting the client and family members The general survey begins immediately when meeting the client and continues throughout the assessment.

When is it necessary for a nurse to change gloves? Select all that apply. a. When touching a noncontaminated client more than once b. Between tasks and procedures on the same client c. Between taking the same client's blood pressure and temperature d. When going from a contaminated area to a cleaner area e. After contact with material that contains a high concentration of microorganisms

b. Between tasks and procedures on the same client d. When going from a contaminated area to a cleaner area e. After contact with material that contains a high concentration of microorganisms The nurse changes gloves (1) between tasks and procedures on the same client after contact with material that contains a high concentration of microorganisms and (2) when going from a contaminated area to a cleaner area. Gloves are removed promptly after use, before touching noncontaminated items and environmental surfaces and before going to another client.

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness? a. Limit position changes as much as possible b. Hand-washing throughout the exam c. Using alcohol swabs to clean the stethoscope d. Draping body areas that are not being assessed.

a. Limit position changes as much as possible Client safety is paramount. For a client who has general muscle weakness, the risk for falls and injury is high. It should be considered the priority to limit position changes during the examination as much as possible. Infection control through washing hands and equipment is important; however, in this case limiting position changes is the priority. Draping body areas not being assessed is needed to ensure client privacy and prevent chilling, however, prevention of a fall must be prioritized due to the client's risk factors.

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? a. Application of firm pressure when using the bell b. Using the diaphragm to listen to low-pitched sounds c. Using the bell to detect high-pitched sounds d. Ensuring that contact with the skin is maintained

d. Ensuring that contact with the skin is maintained While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is a. palpation. b. percussion. c. auscultation. d. inspection.

d. inspection. "I Pay Per Autumn" Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? a. Disinfect the stethoscope before touching the client b. Disinfect the stethoscope after touching the client c. Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface d. Put on a personal protection gown

a. Disinfect the stethoscope before touching the client The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens. Disinfecting the stethoscope after touching the client does not answer the question being asked. Placing the stethoscope directly on the client's skin does not answer the question being asked. Nothing noted in the question would require the nurse to wear a personal protection gown.

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply. a. Eliminate distracting noises from the environment b. Place the diaphragm against the client's clothing c. Readjust the ear pieces to ensure a snug fit d. Angle the binaurals towards the nose e. Tell the client to hold their breath

a. Eliminate distracting noises from the environment c. Readjust the ear pieces to ensure a snug fit d. Angle the binaurals towards the nose To enhance the sounds from the stethoscope, the nurse should eliminate distracting or competing sound from the environment. The ear piece should fit comfortably but snugly in to the ear canals with the binaurals towards the nose to ensure the sounds are transmitted to the ear drums. The stethoscope should be places against the client's skin to prevent rubbing of the clothing. The client should not be instructed to hold the breath because this could alter the heard sounds.

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

a. Eliminate distracting noises from the environment. The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noises from the environment to ensure that the sounds heard are those of the client and not the environment. Using good lighting, preferably sunlight, looking and observing before touching the client, and comparing the appearance of symmetric body parts are some of the guidelines to perform the technique of 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? a. Knee-chest b. Prone c. Supine d. Dorsal recumbent

a. Knee-chest The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.

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

a. Light palpation The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

The nurse wears gloves for which of the following purposes? Select all that apply. a. Prevent transmission of flora from client to client. b. Increase the risk of the nurse acquiring infection from the client. c. Limit exposure to body fluids and secretions d. Facilitate contamination of the hands of the nurse.

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

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 client. The nurse should be aware of what risk when using this assessment technique? a. Risk for injury b. Risk for infection c. Risk for chronic pain d. Risk for impaired skin integrity

a. Risk for injury With deep palpation, you might say, "I'm going to touch you and push down more deeply than before. Let me know if you feel pain or want me to stop." As palpation proceeds, continue conversation, asking the client about pain, presenting symptoms, or contributing factors while observing for nonverbal signs of tenderness or discomfort.

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? a. Snellen chart b. Ophthalmoscope c. Opaque card d. Penlight

a. 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.

Which illustrates the nurse using the technique of inspection? a. The nurse detects a fruity odor of the client's breath. b. The nurse notes increased warmth surrounding the client's incision. c. The nurse notes a rhythmic lub-dub over the client's anterior thorax. d. The nurse detects tympany over the client's lower abdomen

a. The nurse detects a fruity odor of the client's breath. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the client's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

Which is an example of palpation? Select all that apply. a. The nurse detects a small mass in the epigastric area. b. The nurse detects crepitus over the individual's thorax. c. The nurse detects increased warmth surrounding an abdominal incision. d. The nurse detects fruity odor of the client's breath. e. The nurse detects dullness over the liver.

a. The nurse detects a small mass in the epigastric area. b. The nurse detects crepitus over the individual's thorax. c. The nurse detects increased warmth surrounding an abdominal incision. The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

How should the nurse place the ear of an adult when using the otoscope? a. Up and back b. Down and back c. Up and forward d. Down and forward

a. Up and back When using the otoscope on an adult, the ear should positioned up and back.

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? a. palpation b. inspection c. percussion d. auscultation

a. palpation Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.

The nurse is having difficulty visualizing the apical impulse during a physical examination of the cardiovascular system. Which assessment tool is required for a more accurate assessment? a. penlight b. tape measure c. stethoscope d. cup of water

a. penlight A penlight provides tangential lighting and is optimal for inspecting structures such as the jugular venous pulse, thyroid gland, and apical impulse of the heart. It casts light across body surfaces that shows contours, elevations, and depressions, whether moving or stationary, into sharper relief. Although a tape measure is required for the assessment of the cardiovascular system, it is not for visualization. A stethoscope allows the nurse to auscultate the apical impulse not visualize it. A cup of water would be required if the nurse was assessing the thyroid gland.

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? a. Supine b. Lithotomy c. Standing d. Prone

b. Lithotomy The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client lying on her back with the hips at the edge of the examination table and the feet supported by stirrups. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the standing position, the client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint.

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? a. Gather as much general information as possible b. Pay attention to the details while observing c. Write down as many details as possible during the observation d. Not to let the client know he is being observed

b. Pay attention to the details while observing It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. "Gather as much general information as possible" is incorrect because it is specific information, not general information, that is being gathered; "Write down as many details as possible during the observation" is incorrect because writing while observing can be a conflict for the nurse; "Not to let the client know he is being observed" is incorrect because it is not important to keep the client from knowing he is being observed.

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? a. Hyper-resonance b. Resonance c. Tympany d. Dullness

b. 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, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.

A 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? a. One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. b. The middle finger of one hand is placed on the body surface and the other middle finger strikes. c. The ulnar surface of one hand is placed against the body surface and vibrations are felt. d. One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.

b. The middle finger of one hand is placed on the body surface and the other middle finger strikes. Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand.

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? a. pad the table b. use as a drape c. collect body fluids d. serve as a head support

b. Use as a drape During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.

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? a. Warm, comfortable room b. Quiet area free of disturbance c. Adequate lighting d. Firm examination bed or table

c. Adequate lighting Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.

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? a. Nonantimicrobial soap and water with friction b. Hand wash with antiseptic soap c. Application of an alcohol-based hand rub d. No washing is needed because hands are not soiled.

c. Application of an alcohol-based hand rub 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.

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? a. Intestines b. Muscles c. Thyroid gland d. Pancreas

c. Thyroid gland Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.

Which action by a nurse demonstrates the correct application of the principles of standard precautions? a. Using an antiseptic hand scrub to cleanse visibly soiled hands. b. Wearing a gown, gloves, and mask for the physical exam c. Wearing gloves when palpating the tongue, lips, & gums d. Change gloves after each body area is examined

c. Wearing gloves when palpating the tongue, lips, & gums The nurse should wear gloves when examining or touching any areas where there is the potential for exposure to blood or body fluids. Gloves are changed between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Wearing a gown, gloves, and mask is not necessary for the entire physical assessment. If hands are visibly soiled, the nurse should wash with soap and water.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? a. Reflex hammer b. Tuning fork c. Tongue depressor d. Coin or key

d. Coin or key The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? a. Finger pads b. Ulnar surface c. Palmar surface d. Dorsal surface

d. Dorsal surface The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The finger pads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus.

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? a. Range of motion of the spine b. Posterior chest excursion c. Head and neck range of motion d. Dorsiflexion of the foot

d. Dorsiflexion of the foot Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the client in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the client in the sitting position.

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? a. Reflex hammer b. Skinfold calipers c. Flexible metric measuring tape d. Goniometer

d. Goniometer A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee. Skinfold calipers are used to measure skinfold thickness of subcutaneous tissue. A flexible metric measuring tape may be used for many purposes, including measuring the size of extremities.

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? a. Auscultation, percussion, palpation, inspection b. Percussion, palpation, inspection, auscultation c. Palpation, inspection, auscultation, percussion d. Inspection, palpation, percussion, auscultation

d. Inspection, palpation, percussion, auscultation "I Pay Per Autumn" 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.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? a. Percuss the region before auscultating. b. Palpate the region before auscultating. c. Assist the client to a sitting position. d. Reduce all environmental noise.

d. Reduce all environmental noise. Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the client to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the client in the lying position.