chapter 3 jensen
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
palm of hand
part of hand best for palpation of abdominal assessment
finger pads
part of hand used for palpation of fine discrimination. (pulse, lymph nodes, small lumps, and edema)
palmar surface of fingers
part of hand used for palpation used for assessing firmness, contour, position, size, pain, and tenderness.
To adhere to standard precautions, the nurse should remember to (Select all that apply.)
-wash hands before and after patient contact -change white coat frequently
fingernails should be
1/4 inch or less
otoscope
A device used to look into the ears
A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam?
Collect necessary equipment essential to the exam.
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
When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?
Dorsal hand surface
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?
Inspection, palpation, percussion, auscultation
Auscultation
Listening with a stethoscope
A nurse recognizes that it is best to begin the objective data collection with which procedure?
Measure the client's vital signs, height, and weight
A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?
Ophthalmoscope
When conducting a health assessment, it is sometimes necessary to conduct specific physical assessments that use specialized tools. What are some of these special tools? Select all that apply.
Ophthalmoscope Goniometer Skin-fold calipers
A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?
Skin lesion size
T/F The stethoscope should be directly on the skin
True
The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?
Use the middle finger to deliver two taps
The nurse is caring for the patient who is receiving heparin. The nurse plans to:
Wear clean gloves when administering heparin to the patient
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?
adequate lighting
moderate palpation
assessing abdominal characteristics; palpating 1-2 cm
light palpation
assessing skin texture; palpating 1 cm
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
blunt percussion
the quietest percussion sounds are over
bones
reflex hammer
designed to test neurological responses of the deep tendons to assess for abnormalities of the central or peripheral nervous system.
Bell of stethoscope
detects low pitched heart murmurs
Diaphragm of stethoscope
detects most sounds; lung and heart
Tympany is a percussion sound commonly located in the A. Thorax B. Upper arm C. Abdomen D. Lower leg
c. abdomen
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
T/F The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.
false
inspection
general observation of the patient as a whole
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
The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?
goniometer
which organs or body areas does the nurse auscultate as part of the admitting assessment?
heart, lungs, abdomen.
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.
otoscope
instrument used for visual examination of the ear
opthalmoscope
instrument used to examine the interior of the eye
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
the patient is complaining of abdominal pain. what technique is used to form an overall impression?
light palpation
tympanic
loud, high, moderate, drum-like sound
resonant
loud, low, long, hollow sound
During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing?
lungs
dorsal recumbent
lying on back with legs bent and feet flat
heart sounds
moderate low lub-dub, rhythmic 60-100/min anterior thorax
dull
moderate, high, thud sound
latex allergy
most common in nurses and patients more frequently hospitalized
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 environmental noise
A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?
reflex hammer
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?
risk for injury
For which assessment would the nurse plan to use direct percussion?
sinuses
vesicular lung sounds
soft low pitch rustling, wispy 12-20/min anterior and posterior thorax
blood pressure
soft to loud high pitch swooshing or knocking 60-100/min arm
abdominal sounds
soft to loud high pitch gurgly, intermittent 5-35/min. abdomen
flat
soft, high, short, dull sound
The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?
stethoscope bell
indirect percussion
tap finger or hand placed over body surface
percussion
tapping on the patient to produce sound or elicit tenderness
direct percussion
taps fingers directly on skin
hand hygiene
the most important technique used in preventing and controlling transmission of infection
palpation
to examine by touch
T/F standard precautions are used on every patient because it is not always known if they are infected
true
The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain?
tuning fork
How should the nurse place the ear of an adult when using the otoscope?
up and back
skinfold calipers
used to measure percent body fat
Hyperresonant
very loud, low, long, booming sound