Health Assess Ch. 3

The nurse is evaluating the setting prior to beginning a client's physical examination. The nurse should confirm the presence of which of the following? Select all that apply. A) Adequate lighting B) Cool room temperature C) Quiet surroundings D) Soft chair or table E) Table for equipment F) Door or curtain

A) Adequate lighting C) Quiet surroundings E) Table for equipment F) Door or curtain

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate? A) Ensuring client's privacy by providing an examination gown B) Providing a comfortable, warm room temperature C) Arranging exam equipment on a bedside tray table D) Explaining why standard precautions are being used

A) Ensuring client's privacy by providing an examination gown

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There's no way I'll let you do that to me!î Which response by the nurse would be most appropriate? A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. B) Tell the client that this is the only way she can be checked for cancer. C) Ask the client if she would prefer another practitioner to perform the exam. D) Proceed with the pelvic exam and document the client's protests in the health record.

A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? A) Heart sounds B) Bowel sounds C) Breath sounds D) Femoral pulses

A) Heart sounds

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A) Inspection B) Palpation C) Percussion D) Auscultation

A) Inspection

The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use? A) Newspaper B) Snellen chart C) Ophthalmoscope D) Penlight

A) Newspaper

A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, ìI'd really like to have my mom in the room. That's okay, isn't it?î How should the nurse best respond to the client's request? A) ìOf course. There's a chair in the exam room where she can sit.î B) ìThat's no problem. I'll just have to get you to sign a privacy waiver first.î C) ìThat's fine, but be aware that some of the examinations might be embarrassing for you or her.î D) ìIt's best to undergo the examination alone in order to make sure I get accurate data, but if you really want her present, we can do that.î

A) ìOf course. There's a chair in the exam room where she can sit.î

A nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? A) Parasites B) Blood C) Bacteria D) Fungus

B) Blood

The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client's hand. What action should the nurse perform next? A) Obtain a tissue sample for pathology B) Compare the appearance of the client's other hand C) Palpate the lesions for tenderness and warmth D) Perform health promotion teaching about sun protection

B) Compare the appearance of the client's other hand

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions? A) Depressing the skin 1 to 2 centimeters with the dominant hand B) Feeling the surface structures using a circular motion C) Placing the nondominant hand on top of the dominant hand D) Using one hand to apply pressure and the other hand to feel the structure

B) Feeling the surface structures using a circular motion

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? A) Parasitic infection B) Fungal infection C) Bacterial infection D) Allergic reaction

B) Fungal infection

The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing? A) Extremity edema B) Joint flexion/extension C) Two-point discrimination D) Vibratory sensation

B) Joint flexion/extension

The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? A) Flatness B) Resonance C) Tympany D) Dullness

B) Resonance

The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination? A) Complete the examination as quickly as possible. B) Speak clearly and slowly when explaining a procedure. C) Begin the examination with auscultation instead of inspection. D) Maintain the supine position for each part of the examination.

B) Speak clearly and slowly when explaining a procedure.

The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position? A) Sitting upright B) Supine C) Sims position D) Prone

B) Supine

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment? A) Auscultation can be performed through clothing. B) The diaphragm should be held firmly against the body part. C) The bell of the stethoscope can best detect bowel sounds. D) Use of the bell is reserved for advanced practice nurses.

B) The diaphragm should be held firmly against the body part.

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate? A) Omit intrusive parts of the exam. B) Try to minimize position changes. C) Allow client to remain dressed. D) Dim the room light to ensure privacy.

B) Try to minimize position changes.

A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness? A) Light palpation B) Deep palpation C) Direct percussion D) Blunt percussion

C) Direct percussion

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 assessment data? A) Finger pad surface B) Palmar hand surface C) Dorsal hand surface D) Ulnar hand surface

C) Dorsal hand surface

The nurse is using her fingerpads to palpate a client's body part during the physical examination. Which of the following would the nurse best be able to detect? A) Temperature B) Vibrations C) Pulses D) Fremitus

C) Pulses

A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? A) Mid-arm circumference B) Client's height C) Skin lesion size D) Pupillary size

C) Skin lesion size

The nurse is gathering the necessary equipment preparatory to examining a client's ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain? A) Penlight B) Tongue depressor C) Tuning fork D) Otoscope

C) Tuning fork

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions? A) Performing hand hygiene between examinations of each body part B) Discarding in the trash can the safety pin that was used to assess sensory perception C) Wearing gloves to palpate the tongue and buccal membranes D) Wearing a gown, gloves, and mask during the physical exam

C) Wearing gloves to palpate the tongue and buccal membranes

An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? A) ìPlastic tubing should be longer than 3 feet.î B) ìThe bell is used after using the diaphragm.î C) ìWhen using the bell, push on it lightly.î D) ìA diaphragm picks up low-pitched sounds.î

C) ìWhen using the bell, push on it lightly.î

The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position? A) Chest B) Head C) Peripheral pulses D) Abdomen

D) Abdomen

The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? A) Deep palpation B) Indirect percussion C) Moderate palpation D) Blunt percussion

D) Blunt percussion

A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam? A) Explain the purpose of the interview to the client. B) Construct the client's family genogram. C) Establish the client's reliability as historian. D) Collect necessary equipment essential to the exam.

D) Collect necessary equipment essential to the exam.

The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment? A) Eye goggles B) Face mask C) Cover gown D) Face shield

D) Face shield

A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions? A) Use one hand and depress the skin 1 centimeter. B) Use the dominant hand to depress the skin one-half to three-quarters of an inch. C) Use both hands to depress the skin one-half of an inch. D) Use both hands to depress the skin 1 to 2 inches.

D) Use both hands to depress the skin 1 to 2 inches.

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations? A) Head and neck examination B) Palpation of lymph nodes C) Breast examination D) Vital signs

D) Vital signs