chapter 3

Dorsal surface

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

Supine

A nurse is preparing to assess a client's abdomen. Which client position would be best for this assessment?

Risk for injury

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 patient. The nurse should be aware of what risk when using this assessment technique?

inflamed areas of skin

Light palpation is most appropriate to assess the

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

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

The nurse notes resonance over the individual's thorax.

Which describes the nurse using the technique of percussion?

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?

•Inspection •Palpation •Auscultation

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

palpation

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

Ensuring that contact with the skin is maintained

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?

Braden scale

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?

•Lithotomy

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?

Ophthalmoscope

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

Heart murmur

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?

Measure the client's vital signs, height, and weight

A nurse recognizes that it is best to begin the objective data collection with which procedure?

Application of an alcohol-based hand 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?

Lower pitched

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

Immediate

At the beginning of the shift, an older adult hospitalized for pneumonia complains of shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

hyperresonance.

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

Examining the tongue

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?

Hyperresonant

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

The nurse notes increased warmth surrounding an abdominal incision.

Which describes the nurse using the technique of palpation?

Prone

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

Light palpation

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

The nurse detects gurgling throughout the abdomen.

Which describes the nurse using the technique of auscultation?

Cranial nerves

You are performing a physical examination on a new patient. What would you be assessing if you were testing the patient's sense of smell?

Adequate lighting

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?

•Palpation

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?

deep palpation.

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

True

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

Ensure that contact with the skin is maintained

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Strength of a reflex

What is used to gauge central and peripheral nervous system disorders?

Light palpation

What physical assessment technique should a nurse use to obtain a pulse on a client?

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

Which illustrates the nurse using the technique of inspection?

Limit position changes as much as possible

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

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

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

dorsal surface of the hand.

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

bone.

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

To determine whether a structure is filled with air or fluid or is a solid structure

While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Low-frequency sounds

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

Inspection, palpation, percussion, 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?

Wood's light

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?

Lie on the back with legs together on the examination table.

A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?

Disinfect the stethoscope before touching the client

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

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

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?

Upon meeting the client and family members

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

blunt percussion.

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

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

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.

Otoscope

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?

resonance

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?

Measure the client's vital signs, height, and weight.

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

To determine vibration sense in the neuromuscular system

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?

Reduce all environmental noise.

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

use as a drape

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

•Between tasks and procedures on the same client •When going from a contaminated area to a cleaner area •After contact with material that contains a high concentration of microorganisms

When is it necessary for a nurse to change gloves? Select all that apply

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

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?

Skinfold calipers

A nurse is preparing 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?

Goniometer

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?

Coin or key

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Wearing gloves when palpating the tongue, lips, & gums

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

•The nurse notes gurgling sounds over the individual's abdomen. •The nurse notes crackling over the individual's thorax. •The nurse notes a rhythmic lub-dub over the patient's anterior thorax.

Which is an example of auscultation? Select all that apply.

Snellen chart

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?

•Gloves •Gown •Face shield

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

Knee-chest

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?

Application of an antiseptic handrub

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, non-intact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

blunt percussion.

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing

Balance

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

c, d, e, b, a

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

Dorsiflexion of the foot

The nurse is conducting a physical examination of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?