Health Assessment PrepU Chp. 03

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement? a. Skin lesion size b. Pupillary size c. Client's height d. Mid-arm circumference

a A centimeter scale rule most likely would be used to measure the size of a skin lesion. A flexible tape measure would be appropriate to measure mid-arm circumference. A vertical scale in inches or meters would be appropriate to measure a client's height. Pupil size is measured in millimeters.

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

a 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.

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. Reduce all environmental noise. b. Percuss the region before auscultating. c. Assist the client to a sitting position. d. Palpate the region before auscultating.

a 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.

Which of the following is a component of the general survey? a. Patient's state of hygiene b. Patient's blood pressure c. Patient's breath sounds d. Patient's oral temperature

a During the general survey, the nurse should note the client's general state of health, build, and sexual development. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath. Watch the client's facial expressions and note manner, affect, and reactions to people and things in the environment. Listen to the client's manner of speaking and note the state of awareness or level of consciousness. Measure height and weight.

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

a 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).

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

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

a 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.

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment? a. stethoscope bell b. sphygmomanometer c. Doppler d. stethoscope diaphragm

a The bell of the stethoscope is used to auscultate low-pitched sounds. Doppler is used to detect pulses and blood flow. A sphygmomanometer is used to measure blood pressure. The diaphragm of the stethoscope is used to auscultate high-pitched sounds.

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information? a. Dorsal hand surface b. Finger pad surface c. Ulnar hand surface d. Palmar hand surface

a The dorsal or back surface of the hand is most sensitive to temperature and should be used to assess the temperature of the feet of an older adult client with diabetes. The finger pads are sensitive to fine discriminations, pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is sensitive to vibrations, thrills, and fremitus.

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 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.

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

a 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.

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? a. Turn down the volume if the television or radio is on. b. Ask the client to take deep breaths. c. Turn down the lights in the room. d. Ensure that the client is lying down.

a When completing a manual blood pressure assessment, it is important to ensure that external noise does prevent the nurse's ability to hear the systolic and diastolic blood pressure sounds. Turning the television volume down assists the nurse in obtaining a more accurate measurement of the blood pressure. Turning down the lights in the room could prevent the nurse from being able to read the blood pressure accurately. The client may sit or lie down; having the client lie down is not necessary for an accurate reading. Asking the client to take deep breaths would promote relaxation; however, it would not improve the accuracy of the assessment.

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

a, b, c 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.

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

a, b, d 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.

What included in personal protective equipment? Select all that apply. a. Gown b. Mouth, nose, eye protection c. Special linen d. Cleaning processes e. Gloves

a, b, e Personal protective equipment (PPE) includes gloves, gown, mouth, nose and eye protection. Special linen and cleaning processes are not part of PPE.

When should the nurse perform hand hygiene? Select all that apply. a. After providing mouth care b. After reconciling the client's medications c. After taking the blood pressure of a client with intact skin d. After removing gloves e. When hands are visibly soiled

a, c, d, e Hand hygiene sometimes means hand washing with soap and water but at other times can involve only decontamination with an alcohol-based hand rub, depending on the circumstance. Hand hygiene is required when the nurse's hands are visibly soiled, after removing gloves, after providing mouth care, and after taking the blood pressure of a client with intact skin. Reconciling the client's medications means comparing the medications the client is prescribed and is actually using to new medications that are ordered to resolve any discrepancies; this activity does not require hand hygiene.

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) a. Wash hands. b. Dim the lighting to promote comfort c. Obtain and check needed equipment. d. Turn on relaxing music of the client's choice e. Identify ways to ensure client privacy.

a, c, e Prior to conducting a physical examination of a client, the nurse should obtain and check needed equipment, identify how to maintain client privacy during the examination, and wash hands before beginning the examination. Having any additional noise in the background will make it difficult to obtain an accurate assessment. All environmental noise should be removed as much as possible. Good lighting is needed to ensure an accurate assessment. Dim lights can prevent getting a good visual of the area being assessed.

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? a. respiratory b. peripheral vascular c. gastrointestinal d. genitourinary

b A tuning fork has two uses in the physical examination. The most common is to assess hearing however the tuning fork is also used to assess the sense of vibration when completing the neurologic or peripheral vascular assessment. A tuning fork is not used to assess the respiratory, genitourinary or gastrointestinal systems.

A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam? a. Establish the client's reliability as historian. b. Collect necessary equipment essential to the exam. c. Explain the purpose of the interview to the client. d. Construct the client's family genogram.

b Collecting all equipment for the exam promotes organization, displays competence, and avoids having to leave the client to obtain missing items. Interviewing skills are important for obtaining the health history. Constructing a genogram is part of the data collected for family health history. Establishing the client's reliability as a historian should be done before obtaining the health history.

The nurse would use what part of the hand when assessing temperature during palpation? a. Palmar surface b. Dorsal surface c. Finger pads d. Ulnar surface

b The dorsal surface is used for temperature. 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.

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate? a. Tell the client that this is the only way she can be checked for cancer. b. Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. c. Proceed with the pelvic exam and document the client's protests in the health record. d. Ask the client if she would prefer another practitioner to perform the exam.

b The nurse should explain to the client the importance of the examination and the risk of missing important information if any part is omitted. However, whether or not to have the examination is the client's decision and must be respected.

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

b 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.

To adhere to standard precautions, the nurse should remember to do which? Select all that apply. a. Wear gloves for each client contact. b. Remove any personal protective equipment (PPE) before leaving client's room. c. Perform hand hygiene before and after direct client contact. d. When a gown is required, reuse gown when reinitiating contact with the same client.

b, c Hand hygiene should be performed before having direct contact with any client and after contact with intact skin, nonintact skin, blood, body fluids or excretions, mucous membranes, wound dressings, and inanimate objects in the immediate vicinity of the patient, as well as after removing gloves. PPE should be removed before leaving the client's room or cubicle. Gloves are necessary when the nurse will be providing direct client care, and gloves should also be worn when cleaning the environment or medical equipment. Gloves may not be necessary when interviewing or teaching the client, for example. Gowns should never be reused, even when the gown was worn while caring for the same client.

Which of the following techniques are used in a physical assessment? Select all that apply. a. Subjectivity b. Auscultation c. Questioning d. Palpation e. Inspection

b, d, e The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment. Subjectivity and questioning are not techniques of inspection for physical assessment.

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility? a. stadiometer b. test tubes c. goniometer d. speculum

c A goniometer is used to measure degree of flexion and extension of joints. A speculum is used to examine the ear canals. Test tubes are used to measure temperature sensation. A stadiometer is used to measure height.

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? a. Mask, protective eye goggles, gown b. Mask, protective eye goggles c. Gloves, mask, protective eye goggles, gown d. Gloves, gown

c 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.

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. very deep palpation. c. deep palpation. d. moderate palpation.

c 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.

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

c 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.

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? a. Deep b. Moderate c. Light d. Intermediate

c Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate is not typically used to describe palpation.

When performing a physical assessment on an older adult client, what should the nurse consider offering this client? a. A family member in the room b. Elevation of the head of the examination table c. An extra blanket d. A pillow

c Older adults may chill more easily than younger clients, so the nurse should consider offering them an additional blanket or drape. It is not necessary to consider offering the client to have a family member in the room or a pillow. The nurse should elevate the head of the examination table for any client, not in particular for an older adult client.

What guidelines should the nurse keep in mind while performing auscultation? a. Use good lighting, preferably sunlight b. Look and observe before touching the client c. Eliminate distracting noise from the environment d. Compare appearance of symmetric body parts

c The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noise from the environment to ensure that the sounds that are 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.

The nurse is planning to assess for the presence of lower pitch sounds when examining a client's heart. Which item of equipment would the nurse use to make this assessment? a. Two test tubes b. Tuning fork c. Bell of a stethoscope d. Diaphragm of a stethoscope

c The bell of the stethoscope transmits lower pitched sounds. A tuning fork is used to assess hearing and not lower pitch sounds. Test tubes are not used to assess sound. The diaphragm of the stethoscope is used to assess higher pitch sounds.

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 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.

Universal precautions are primarily designed to protect the health care worker from what? a. Musculoskeletal injuries b. STDs c. Blood-borne pathogens d. Respiratory diseases

c 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 is caring for the client who is receiving heparin. The nurse plans to: a. Perform hand hygiene with alcohol-based gel after administering the heparin b. Wear a mask when administering heparin to the client c. Recap the needle after administering heparin to the client d. Wear clean gloves when administering heparin to the client

d Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? a. Percussion, palpation, inspection, auscultation b. Auscultation, percussion, palpation, inspection c. Inspection, auscultation, percussion, palpation d. Inspection, palpation, percussion, auscultation

d Inspection is the first physical assessment technique that a nurse should implement. This prevents altering the appearance of structures that may distract the nurse from completing a focused observation.

A nurse recognizes that it is best to begin the objective data collection with which procedure? a. Begin at the head and move in a systematic approach b. Allow the client to undress and put on a gown c. Auscultation of all necessary body systems to prevent disturbing any organs d. Measure the client's vital signs, height, and weight

d It is important to begin the assessment with less intrusive procedures such as vital signs and height & 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.

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? a. Percussion b. Auscultation c. Inspection d. Palpation

d Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub? a. Use when the hands are visibly soiled b. Rub only the palms of the hands c. Dry the hands on available paper towels d. Rub the hands and fingers until dry

d Proper technique for using alcohol-based hand rubs is necessary to be effective. The nurse then rubs both hands together, making sure to cover all surfaces of the fingers and hands until they are dry. When an alcohol-based rub is used, all surfaces of the hand must be covered. Alcohol-based hand rub cannot be used when the hands are visibly soiled. Using paper towels to dry the hands is not the proper technique.

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

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

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment? a. Auscultation can be performed through clothing. b. The bell of the stethoscope can detect bowel sounds. c. The binaurals connect the tubing to the chest piece. d. The diaphragm should be held firmly against the body part.

d The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing.

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. No washing is needed because hands are not soiled. d. Application of an alcohol-based hand rub

d 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.

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

d The nurse could 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, non-intact 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 percussion? a. The nurse detects crepitus over the individual's thorax. b. The nurse notes symmetry of the individual's thorax. c. The nurse detects rustling over the individual's thorax. d. The nurse notes resonance over the individual's thorax.

d 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.

What is the nurse's primary role in subjective data collection? a. To diagnose illness b. To determine health risks c. To identify needs d. To improve the client's health status

d The nurse's role in subjective data collection is to gather information to improve the client's health status and to help determine the cause of the client's current symptoms. The identification of needs and risks are part of the assessment. Nurses do not diagnose illnesses.

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? a. Back b. Abdomen c. Neck d. Lungs

d To assess the client's breathing sounds, the nurse auscultates the lungs using the stethoscope.

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

d 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.