chapter 3

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

Alcohol-based rub

What would be the expected tone elicited by percussion of a normal lung? You Selected: Resonance

Resonance

For which assessment would the nurse plan to use direct percussion? Sinuses Kidneys Liver Gallbladder

Sinuses

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

Strength of a reflex

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

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

Which describes the nurse using the technique of percussion? The nurse notes resonance over the individual's thorax. The nurse detects crepitus over the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects rustling over the individual's thorax.

The nurse notes resonance over the individual's thorax.

When should the nurse wear gloves? Select all that apply. Prior to washing hands When touching blood or body fluids In anticipation of body fluid contact When taking an oral temperature When monitoring vital signs

When touching blood or body fluids In anticipation of body fluid contact

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? Wood's light Penlight Magnifying glass Examination light

Wood's light

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using firm percussion. direct percussion. indirect percussion. blunt percussion.

blunt percussion.

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 hyperresonance. tympany. dullness. flatness

hyperresonance.

he nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination? palpation inspection percussion auscultation

percussion

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

Application of an alcohol-based hand rub

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? Cervical spine Thorax Axillary nodes Balance

Balance

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? Snellen E chart Braden scale Penlight Reflex (percussion) hammer

Braden scale

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

Coin or key

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? Cranial nerves Nose Upper neuron function Strength of nerve functioning

Cranial nerves

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 Respiratory rate of 20 breaths per minute Elevated blood pressure while lying in bed Temperature of 97.6 degrees Fahrenheit

Decreased breath sounds unilaterally

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

Dorsal surface

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. Eliminate distracting noises from the environment Place the diaphragm against the client's clothing Readjust the ear pieces to ensure a snug fit Angle the binaurals towards the nose Tell the client to hold their breathe

Eliminate distracting noises from the environment Readjust the ear pieces to ensure a snug fit Angle the binaurals towards the nose

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

Examining the tongue

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. Nasopharyngeal airway Gloves Gown Face shield Stethoscope

Gloves Gown Face shield

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? Reflex hammer Skinfold calipers Flexible metric measuring tape Goniometer

Goniometer

The nurse would use the tuning fork to assess for what? Hearing loss Eye movement Visualization Reflexes

Hearing loss

Deep palpation is used to: Identify abdominal contents Evaluate surface characteristics Elicit deep tendon reflexes Determine the density of a structure

Identify abdominal contents

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. It is often the source of the most physical signs. To maximize findings, local inspection should be conducted prior to general inspection. The acuity of the client will determine whether general or local inspection should be implemented in the examination.

It is often the source of the most physical signs.

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 Prone Supine Dorsal recumbent

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? Supine Lithotomy Standing Prone

Lithotomy

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

Low-frequency sounds

As the density of tissue decreases, the percussion note becomes: Softer Shorter Lower pitched Less musical

Lower pitched

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

Ophthalmoscope

A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination? Dorsal recumbent Standing Supine Prone

Prone

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

Resonance

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

Shape of abdominal mass Size of liver Pulsation of abdominal aorta

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? Platform scale with height attachment Metric ruler Sphygmomanometer Skinfold calipers

Skinfold calipers

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 Ophthalmoscope Opaque card Penlight

Snellen chart

The ulnar edge of the hand is highly receptive to which of the following sensations? Moisture and contour Vibrations and moisture Contour and temperature Temperature and vibrations

Temperature and vibrations

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

The nurse detects a small mass in the epigastric area. The nurse detects crepitus over the individual's thorax. The nurse detects increased warmth surrounding an abdominal incision.

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

The nurse notes increased warmth surrounding an abdominal incision.

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? Intestines Muscles Thyroid gland Pancreas

Thyroid gland

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

True

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound? Resonance Hyper-resonance Tympany Dullness

Tympany

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using inspection. palpation. Doppler magnification. percussion.

percussion.

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

Hand hygiene

The examiner should use hand washing instead of an alcohol-based hand rub: If the patient has an infection with Mycobacterium tuberculosis If the patient has an infection with Clostridium difficile If the patient has an infection with hepatitis B virus

If the patient has an infection with Clostridium difficile

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? Fingertips Palmar surface Dorsal surface Finger pads

Palmar surface

For which assessment would the nurse plan to use light palpation? Papular rash Shape of abdominal mass Size of liver Pulsation of abdominal aorta

Papular rash

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

Pay attention to the details while observing

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? Hyper-resonance Resonance Tympany Dullness

Resonance

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

Hyperresonant

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

Limit position changes as much as possible

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

Prevent transmission of flora from client to client. Limit exposure to body fluids and secretions

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? Risk for injury Risk for infection Risk for chronic pain Risk for impaired skin integrity

Risk for injury

When performing indirect percussion, the examiner: Strikes the flank area with the palm of the hand Strikes the stationary finger at the distal interphalangeal joint Strikes the stationary finger at the proximal interphalangeal joint Taps fingertip over bony processes

Strikes the stationary finger at the distal interphalangeal joint

Which describes the nurse using the technique of auscultation? The nurse detects gurgling throughout the abdomen. The nurse detects foul odor of the urine. The nurse notes a small nodule in the breast. The nurse notes dullness over the liver.

The nurse detects gurgling throughout the abdomen.

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 To determine reflex sensation in the legs To determine sensation in the scalp To determine genetic hearing loss in infants

To determine vibration sense in the neuromuscular system

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

Upon meeting the client and family members

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 hyperresonance. tympany. dullness. flatness.

hyperresonance.

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a 1-inch bell. 1½-inch diaphragm. 15-inch flexible tubing. 1-inch diaphragm.

1½-inch diaphragm.

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? Handwashing Wearing latex gloves Using eye protection Gowning

Handwashing

How should the nurse place the ear of an adult when using the otoscope? Up and back Down and back Up and forward Down and forward

Up and back