Chapter 3: Collecting Objective Data Prep U

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

Tangential lighting

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations

A student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed?

The bell of the stethoscope is used to auscultate bowel sounds.

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?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

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

For which of the following assessments would the nurse plan to use deep palpation?

-Shape of abdominal mass -Size of liver -Pulsation of abdominal aorta

For which of the following assessments would the nurse plan to use light palpation?

-Skin temperature -Skin texture -Skin rash

For which client should the nurse wear gloves to provide care? Select all that apply.

-The client with Clostridium difficile -The client with vancomycin-resistant enterococci -The client requiring oropharyngeal suctioning

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

1 1/2 inch diaphragm

What can the nurse assess using percussion?

Borders of the heart

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

A nurse is preparing the perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment

A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?

Explain to the client why the assessment is important and the possibility of missing important findings.

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?

Goniometer

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.

As the density of tissue decreases, the percussion note becomes:

Lower pitched

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

You are performing a shift assessment as you begin caring for one of your clients. What is the most effective assessment technique for the lymph nodes of the neck?

Palpation

For which assessment would the nurse plan to use light palpation?

Papular rash

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment?

Prone

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

What is the nurse's primary role in subjective data collection?

To improve the client's health status

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

Tympany

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

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

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?

auscultation

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

When the nurse places on 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

blunt percussion

When examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand.

The most commonly used method of percussion is

indirect percussion

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

indirect percussion

The 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?

percussion

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion

For which assessment would the nurse plan to use direct percussion?

Sinuses