Jensen's Health Assessment 3rd Ed. | Chapter 3
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?
Inspection, palpation, percussion, auscultation
A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?
Palpation
Which of the following is a component of the general survey?
Patient's state of hygiene
The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?
Use the middle finger to deliver two taps
When performing a physical assessment on an older adult client, what should the nurse consider offering this client?
An extra blanket
The nurse is assessing a client. Which body area will the nurse use the diaphragm of the stethoscope to assess? Select all that apply.
Breath sounds Heart sounds Bowel sounds
Prior to beginning the physical examination, the nurse should perform which actions to ensure the examination flows smoothly? Select all that apply.
Check the batteries in the penlight. Check to ensure the otoscope is functioning. Clean the stethoscope.
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
Which of the following statements is true of the role of inspection in the physical examination?
It is often the source of the most physical signs.
Which of the following statements is true of the role of inspection in the physical examination?
It should be performed after auscultation but before palpation and percussion.
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.
A nurse performs indirect palpation of an underlying structure correctly when the hands are placed in which position?
Middle finger of one hand is placed on the body surface and the other middle finger strikes
When conducting a health assessment, it is sometimes necessary to conduct specific physical assessments that use specialized tools. What are some of these special tools? Select all that apply.
Ophthalmoscope Goniometer Skin-fold calipers
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?
Palmar surface
The nurse wears gloves for which of the following purposes? Select all that apply.
Prevent transmission of flora from client to client. Limit exposure to body fluids and secretions
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?
Skin lesion size
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?
Thyroid gland
Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?
To determine vibration sense in the neuromuscular system
The most commonly used method of percussion is
indirect percussion
A new graduate nurse is having trouble charting the details of a shift assessment on a patient. The preceptor of the new nurse explains to the nurse that accurate descriptions are essential for
legal documentation
A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?
reflex hammer
