Missed questions on quiz (health assessment)

The sounds detected using auscultation are classified according to the intensity:

(loud or soft), pitch (high or low), duration (length), and quality (musical, crackling, raspy) of the sound

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?

Actual Nursing Diagnosis

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

A novice nurse is struggling with making accurate nursing diagnoses. The supervisor, a much more experienced nurse, counsels the novice on what characteristics help nurses make better diagnoses. Which of the following should the supervisor mention? Select all that apply.

Awareness of when exceptions apply to rules A focus on the big picture Years of experience Seeing shades of gray when making decisions

Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes?

Bedside hand-off reports

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

Coin or key

Moderate palpation:

Depress the skin surface 1 to 2 cm (0.5 to 0.75 in) with your dominant hand, and use a circular motion to feel for easily palpable body organs and masses. Note the size, consistency, and mobility of structures you palpate.

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

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?

Dorsiflexion of the foot

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

Examining the tongue

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs.

Which of the following should the nurse do before conducting a physical examination of a client

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

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

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

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

Strength of a reflex

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

Tangential lighting

Which illustrates the nurse using the technique of inspection?

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

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

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?

To determine vibration sense in the neuromuscular system

How should the nurse place the ear of an adult when using the otoscope?

Up and back

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

Upon meeting the client and family members

What can the nurse use to learn new information and add to their knowledge base?

What can the nurse use to learn new information and add to their knowledge base?

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?

Wood's light

When the nurse knows after drawing an inference that there is a need for both medical and nursing interventions, the patient's problem is which type?

collaborative problem

The three types of percussion:

direct, blunt, and indirect

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should

explain the role and purpose of the nurse.

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question?

family violence

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.

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

inspection.

direct (percussion):

is the direct tapping of a body part with one or two fingertips to elicit possible tenderness (e.g., tenderness over the sinuses)

4 types of palpation:

light, moderate, deep, manual

During the interview of an adult client, the nurse should

provide the client with information as questions arise.

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following

too many or too few data

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

use very basic lay terminology.

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

Alcohol-based 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

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

Be nonjudgmental and keep an open mind. Use rationale to support opinions or decisions. Acquire an adequate knowledge base that continues to build

A patient has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the patient's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Collaborative problem

A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?

Color

Percussion has several different assessment uses, including:

Eliciting pain: -Percussion helps detect inflamed underlying structures. If an inflamed area is percussed, the client's physical response may indicate or the client will report that the area feels tender, sore, or painful. Determining location, size, and shape: -Percussion note changes between borders of an organ and its neighboring organ can elicit information about location, size, and shape. -Determining density: Percussion helps determine whether an underlying structure is filled with air or fluid or is a solid structure. -Detecting abnormal masses: Percussion can detect superficial abnormal structures or masses. Percussion vibrations penetrate approximately 5 cm deep. Deep masses do not produce any change in the normal percussion vibrations. -Eliciting reflexes: Deep tendon reflexes are elicited using the percussion hammer.

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?

Ensuring that contact with the skin is maintained

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 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

Deep palpation:

Place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure (Fig. 3-2). This should result in a surface depression between 2.5 and 5 cm (1 and 2 in). This allows you to feel very deep organs or structures that are covered by thick muscle.

The nurse wears gloves for which of the following purposes? Select all that apply.

Prevent transmission of flora from patient to patient. Limit exposure to body fluids and secretions

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

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Review the client's prescribed medication orders.

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.)

Shape of abdominal mass Size of liver Pulsation of abdominal aorta

For which assessment would the nurse plan to use direct percussion

Sinuses

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?

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

Light palpation:

To perform light palpation (Fig. 3-1), place your dominant hand lightly on the surface of the structure. There should be very little or no depression (less than 1 cm). Feel the surface structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture.

Bimanual palpation:

Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated (Fig. 3-3). Use one hand to apply pressure and the other hand to feel the structure. Note the size, shape, consistency, and mobility of the structures you palpate.

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.

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

dorsal surface of the hand.

Indirect or mediate percussion:

is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures. As density increases, the sound of the tone becomes quieter. Solid tissue produces a soft tone, fluid produces a louder tone, and air produces an even louder tone.

Blunt (perussion):

is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

nursing diagnosis

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

palpation

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

percussion.

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the patient has the opportunity for an enhanced health state:

wellness diagnosis

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

working.