Chapter 3: Collecting Objective Data: The Physical Examination

What body type is a lean, slightly muscular body build? A. Ectomorph B. Endomorph C. Mesomorph

A. Ectomorph

During an assessment of the lungs of an adult client with emphysema, the nurse anticipates that during percussion the client will exhibit: A. Hyperresonance B. Tympany C. Dullness D. Flatness

A. Hyperresonance

Name at least five things that can be collected from a general survey:

Observations, dress, hygiene, posture/gait, body build and fat distribution, level of consciousness, level of comfort behavior, speech

What is the primary purpose of documentation?

Provides an assessment database- the foundation of the nursing process

What is used to test distant vision and near vision?

Snellen E chart (distant vision) and Rosenbaum chart or newspaper (near vision)

What equipment does a nurse need in order to assess vital signs?

blood pressure cuff (sphygmomanometer), stethoscope, thermometer, watch, pain scale

What would the nurse use to assess the eyes?

opthamoscope

What would the nurse use to assess the ears?

otoscope

While percussing an adult during a physical examination the nurse can expect to hear flatness over the patient's: A. Lungs B. Bone C. Liver D. Abdomen

A. Lungs

Before beginning a physical assessment of a client, the nurse should first: A. Wash both hands with soap and water B. Determine whether the client is anxious C. Ask the client to remove all clothing D. Request a family member to be present

A. Wash both hands with soap and water

What are the three types of assessment forms?

Admitting database, ongoing, focused/specialized

What is used to assess pressure sore risk?

Braden scale

During palpation of a patient's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing: A. Light palpation B. Moderate palpation C. Deep palpation D. Bimanual palpation

C. Deep palpation

While examining a client, the nurse plans to palpate temperature of the skin by using the: A. Fingertips of the hand B. Ulnar surface of the hand C. Dorsal surface of the hand D. Palmar surface of the hand

C. Dorsal surface of the hand

The most common method of percussion is: A. Direct percussion B. Mild percussion C. Indirect percussion D. Blunt percussion

C. Indirect percussion

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is: A. Palpation B. Percussion C. Auscultation D. Inspection

D. Inspection

While performing a physical exam on an adult patient, the nurse can detect the density of an underlying structure by using: A. Inspection B. Palpation C. Doppler magnification D. Percussion

D. Percussion

True/False The nurse should auscultate, using the stethoscope, over the clothing to ensure that the patient does not feel uncomfortable.

False

What should you do if you make a documentation error when writing something in pen?

Put one line through the error, write "error, write initials, credentials, date, and time

What would a nurse be doing if the patient was in Sim's position?

enema administration, digital rectal exam, inserting a suppository