PrepU Health Assess Ch. 3 Assignment 3

What included in personal protective equipment? Select all that apply.

-Gloves -Gown -Mouth, nose, eye protection

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

-Inspection -Palpation -Auscultation

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

-Obtain and check needed equipment. -Identify ways to ensure patient privacy. -Wash hands.

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?

Adequate lighting

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?

Application of an alcohol-based hand rub

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?

Ask permission to talk to the client in front of visitors.

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

Balance

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Consult with a clinical instructor.

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

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

Disinfect the stethoscope before touching the client

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

Dorsal surface

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

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

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?

Knee-chest

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?

Lithotomy

During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing?

Lungs

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?

Palpation

Your lab instructor explains that physical examination relies on what cardinal assessment technique? Percussion

Percussion Blood-borne pathogens

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

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound?

Tympany

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

Wearing gloves when palpating the tongue, lips, & gums

Light palpation is most appropriate to assess the

inflamed areas of skin

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?

light

What would be the expected tone elicited by percussion of a normal lung?

Resonance

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?

Braden scale

The nurse would use the tuning fork to assess for what?

Hearing loss

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