Chapter 3: Collecting Objective Data: The Physical Examination

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

Which illustrates the nurse using the technique of inspection?

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

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

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 client privacy. -Wash hands.

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

Alcohol-based rub

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

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?

Braden scale

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.

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

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

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

When assessing pulses, the nurse would use which part of the hand for palpation?

Finger pads

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

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

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 techniques are used in a physical assessment? Select all that apply.

Inspection Palpation Auscultation

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

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

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

Light palpation

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

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

Lungs

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise.

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

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

Resonance

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

To improve the client's health status

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

Turn down the volume if the television or radio is on.

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

Wearing gloves when palpating the tongue, lips, & gums

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

auscultation

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone.

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

deep palpation.

Light palpation is most appropriate to assess the

inflamed areas of skin

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

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

percussion

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?

Skinfold calipers