Module 7 (Physical Assessment)

B.) Palpation of lymph nodes [Pg. 562]

A client complains of sore throat, fever, and cough. Which focused assessment should be performed? A.) Auscultation of heart sounds B.) Palpation of lymph nodes C.) Inspection of the structures of the eye D.) Percussion of the lungs

third and fourth heart sounds, murmurs and clicks. [Davis Advantage]

Adventitious heart sounds include the?

A.) Preparing the client B.) Preparing the environment C.) Infection Control E.) Preparing the equipment [Pg. 500 - 502]

As the nurse prepares for a physical assessment, what should be considered? Select all that apply. A.) Preparing the client B.) Preparing the environment C.) Infection control D.) Preparing the paperwork E.) Preparing the equipment

D.) First and second intercostal spaces next to the sternum [Pg. 571] "Bronchovesicular breath sounds are heard over the sternum anteriorly and between the scapulae posteriorly."

Bronchovesicular breath sounds are best heard over which area? A.) Midline over the trachea just below the larynx B.) At the base of the lungs near the diaphragm C.) Fourth intercostal space in the midclavicular line D.) First and second intercostal spaces next to the sternum

A.) Temperature B.) Texture C.) Turgor and elasticity [Pg. 508 - 509] "Skin Assessment - observe skin color, lesions, and other characteristics. Also notice unusual odors." "Skin color, Skin Characteristics (Skin Temperature, Moisture, Texture, Turgor-Swollen tissue may feel tender to touch), Skin Lesions (Normal and Abnormal)" "Edema is not actually a condition of the skin, but it is convenient to assess for it while assessing the skin."

In the assessment of the skin, the nurse should evaluate which components? Select all that apply. A.) Temperature B.) Texture C.) Turgor and elasticity D.) Touch E.) Tenderness

A.) Hearing ability

How should the nurse adapt the assessment for an elderly client? The nurse enters the room of an 86-year-old client admitted with pneumonia. Which aspect should the nurse assess prior to speaking to the client? A.) Hearing ability B.) Presence of family C.) Religious preference D.) Socioeconomic status

C.) Ask the client to count backwards from 100. [Pg. 585]

If a client is ticklish or exhibiting guarding during abdominal palpation, what should the nurse do to facilitate the exam? A.) Palpate with firmer pressure. B.) Palpate with lighter pressure. C.) Ask the client to count backwards from 100. D.) Defer the palpation part of the assessment.

confirm after 5 minutes of Auscultation {Davis Advantage]

If no bowl sounds are heard the nurse should?

C.) Gastrointestinal

In which body system is it necessary to deviate from the usual assessment order of inspection, palpation, percussion, and auscultation? A.) Cardiovascular B.) Skeletal C.) Gastrointestinal D.) Urinary

Inspection Auscultation of major bowel sounds Auscultation of major arteries Percussion Palpate [DavisEdge] "The normal order of assessment would be inspection, palpation, percussion, and auscultation. However, palpation and percussion can interfere with bowel sounds, and especially since this client has a suspected bowel obstruction, the nurse should inspect, then auscultate. Auscultation of the bowel sounds then auscultate the major arteries. After that, the nurse should perform percussion and then palpate the abdomen."

In which order should the nurse perform an abdominal assessment for a client with a suspected bowel obstruction? Palpation Percussion Inspection Auscultation of major arteries Auscultation of major bowel sounds

Inspection Palpation Percussion Auscultation Olfaction [Pg. 503 - 506]

List the steps of physical assessment of most body systems in the appropriate order. Percussion Auscultation Inspection Palpation Olfaction

5 to 15 seconds [Davis Advantage] "If heard less frequently, they are considered hypoactive" "If heard more frequently means they are hyperactive"

Normal bowl sounds should occur every__ to __ seconds?

S - Sleep disorders P - Problems with eating or feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdowns [Pg. 507]

SPICES will help you remember common problems for older adults that require nursing intervention and to focus your assessment as your perform comprehensive physical examination.

All are correct [Pg. 507] -"Appearance and behavior, -Body Type and Posture, -Speech -Mental State -Dress, Grooming, Hygiene -Vital Signs -Height and Weight are all involved in the General Survey, which is your overall impression of the client that begins at first contact and continues throughout the exam."

That nurse is performing a general survey for a newly admitted client. What should be included in this evaluation? Select all that apply. A.) Appearance and behavior B.) Speech C.) Dress, grooming, and hygiene D.) Vital signs E.) Mental state

normal heart sounds. [Davis Advantage]

The first and second heart sounds are considered?

B.) Olfaction

The nurse is performing a dressing change to a decubitus ulcer and inspects the wound. The nurse notices purulent drainage on the old dressing. Which additional assessment technique would the nurse use to determine the presence of infection?. A.) Palpation B.) Olfaction C.) Percussion D.) Auscultation

A.) Select a time when the client is relaxed and receptive. B.) Establish rapport with the client. C.) Alert the client before touching him or her. D.) Consider developmental and cultural differences. [Pg. 502]

The nurse is preparing to perform a physical assessment. What should be included in the preparation of the client? Select all that apply. A.) Select a time when the client is relaxed and receptive. B.) Establish rapport with the client. C.) Alert the client before touching him or her. D.) Consider developmental and cultural differences. E.) Confirm the client is not in pain.

Name Date of Birth or Medical Identification Number *Additionally, the nurse should introduced him or herself and explain the procedure* [Davis Advantage]

The nurse must confirm the client's identity using the identity band and two identifiers which are?

Bilaterally Using Two Fingers. "The nurse should have the client simultaneously squeeze two fingers with both hands so the nurse can compare the strength of each side of the body." [Davis Advantage]

What gripping technique is best to evaluate upper arm strength?

Bilaterally with Dorsa of Hand. [Davis Advantage]

What is the most accurate way for the nurse to assess skin temperature?

Inspection, Auscultation, Percussion, and Palpation "Percussion and palpation stimulate the bowel and may alter bowel sounds, so auscultation is performed directly after inspection." [Davis Advantage]

What order is used when assessing bowl sounds?

A.) Read the last nurse's note and client history.

What should the home health nurse do prior to making a visit to a client he/she has never seen before?. A.) Read the last nurse's note and client history. B.) Ensure that adequate lighting is in place during the visit. C.) Call the health care provider to obtain information. D.) Ask the client to turn off the radio or television during the visit.

Confirm Identity [Davis Advantage]

What should the nurse do first when beginning a physical assessment?

Fingertips in Rotating Motion. "Palpation can help to identify masses or areas of discomfort. Palpation should not be performed deeply if the client is in distress." [Davis Advantage]

What technique should the nurse use for palpation of the abdomen?

C.) Point of maximum impact

When performing auscultation of heart sounds, which describes the small vibration at the 5th intercostal space at the midclavicular line, where the strongest impact of the systolic heart beat is located? A.) Apex B.) Precordium C.) Point of maximum impact D.) Suprasternal notch

C.) Do not push a limb or joint past what is comfortable for the client.

When testing range of motion, what should the nurse do if the client experiences discomfort or resistance?. A.) Continue to push the joint with passive range of motion. B.) Encourage the client to keep trying. C.) Do not push a limb or joint past what is comfortable for the client. D.) Have the client maintain the position of discomfort for a few seconds to see if it will dissipate.

A.) Bronchial [Pg. 571]

Which describes breath sounds auscultated over the trachea? A.) Bronchial B.) Bronchovesicular C.) Vesicular D.) Stridor

B.) Awake, alert, and oriented D.) Mood appropriate for the situation E.) Eye contact [Pg. 508]

Which is a normal assessment finding for mental state and affect? Select all that apply. A.) Lethargy and somnolence B.) Awake, alert, and oriented C.) Confusion and fatigue D.) Mood appropriate for the situation E.) Eye contact

B.) Overall tympany, with dullness over organs or structures [Pg. 583]

Which is a normal finding when percussing the abdominal area? A.) Overall dullness, with tympany over organs or structures B.) Overall tympany, with dullness over organs or structures C.)Dull sounds throughout D.) Fremitus throughout

C.) They should be palpated one at a time. [Pg. 575]

Which is an important consideration when palpating carotid arteries? A.) They should be palpated at the same time. B.) Auscultation should be done before palpation. C.) They should be palpated one at a time. D.) Inspection should reveal visible pulsations.

C.) Gait

Which is part of the assessment of the musculoskeletal system? A.) Reflexes B.) Edema C.) Gait D.) Romberg test

A.) Level of consciousness

Which is referred to as the assessment of arousal and orientation? A.) Level of consciousness B.) Cerebral function C.) Responsiveness D.) Reflexes

A.) Sitting

Which position is best for evaluating a client's posterior lung fields? A.) Sitting B.) Supine C.) Dorsal recumbent D.) Lithotomy

A.) General survey [Pg. 507]

Which describes the first contact and overall impression of the client? A.) General survey B.) In-depth assessment C.) Focused assessment D.) Problem-related assessment

B.) Confusion C.) Incontinence D.) Skin breakdown E.) Evidence of falls

Which factors should the nurse incorporate into the assessment of an older client according to the acronym SPICES? Select all that apply. A.) Seizures B.) Confusion C.) Incontinence D.) Skin breakdown E.) Evidence of falls F.) Problems with mobility

C.) Focused-physical assessment

A client presents to the emergency room and is diagnosed with an exacerbation of chronic obstructive pulmonary disease and is in distress. Which is the best type of assessment for the nurse perform for this client?A.) Ongoing assessment B.) System-specific assessment C.) Focused-physical assessment D.) Comprehensive physical examination

B.) Edema

A client with a history of congestive heart failure complains that all his or her shoes are too tight. Which should this information alert the nurse to? A.) Dehydration B.) Edema C.) Weight gain D.) Constipation

D.) Dehydration [Pg. 509]

A nurse is admitting a client who has a 3-day history of vomiting and diarrhea. On initial assessment, the nurse notices that the client has poor skin turgor. Which is this a likely indication of? A.) Infection B.) Fever C.) Malnutrition D.) Dehydration

D.) Psychiatric disorders

A nurse is performing an assessment and asks a client how he or she has been feeling lately. The client responds, "yellow." What should the nurse assess further after hearing this answer?. A.) Anxiety B.) Substance abuse C.) Early dementia D.) Psychiatric disorders

C.) Leave the door open to allow lighting.

A student nurse enters the room of a client and begins the assessment while the registered nurse observes. Which action made by the student nurse requires correction by the registered nurse? A.) Ask any visitors to leave the room. B.) Turn on the lights in the client's room. C.) Leave the door open to allow lighting. D.) Gather all supplies prior to entering the room.

C.) 5 full minutes

The nurse documents in the medical record of a client the absence of bowel sounds. How long should the nurse listen to the abdomen prior to documenting this finding? A.) 1 full minute B.) 3 full minutes C.) 5 full minutes D.) 10 full minutes

C.) Wheezes noted upon direct auscultation. [Pg. 506]

The nurse enters the room of a client and can hear the client wheezing without the use of the stethoscope. How should the nurse document this finding in the medical record? A.) Wheezes noted upon inspection. B.) Wheezes noted upon percussion. C.) Wheezes noted upon direct auscultation. D.) Wheezes noted upon indirect auscultation.

C.) Third heart sound D.) Fourth heart sound E.) Murmur [Pg. 577] "Abnormal findings: Extra sounds (S3 or S4) murmurs, clicks, or rubs."

The nurse hears some adventitious heart sounds when auscultating the anterior chest. What could the nurse be hearing? Select all that apply. A.) First heart sound B.) Second heart sound C.) Third heart sound D.) Fourth heart sound E) Murmur

A.) Minimize unhealthy food choices. C.) Refrain from use of tobacco products. E.) Identify any risk factors for depression or suicide. [Pg. 507]

The nurse working in a clinic is preparing to assess a female adolescent. Which education should the nurse provide during the examination? Select all that apply. A.) Minimize unhealthy food choices. B.) Let the client help with the exam. C.) Refrain from use of tobacco products. D.) Allow the teenager to examine the equipment. E.) Identify any risk factors for depression or suicide.

A.) Allow the toddler to make choices. C.) Administer needed immunizations last. [Pg. 506]

The parents and their toddler present to the clinic for a well-child check-up. Which differences would the nurse incorporate into the assessment since the client is a child? Select all that apply.. A.) Allow the toddler to make choices. B.) Let the child play with the equipment. C.) Administer needed immunizations last. D.) Hold the toddler against the parent's chest. E.) Promote and support the child's independence.

A.) Auscultate each side and compare findings. B.) Document the findings in the client's medical record. D.) Use the diaphragm of the stethoscope to listen to lung sounds. [Pg.572]

Which actions should the nurse include when preparing to auscultate lung sounds in a client with congestive heart failure. Select all that apply. A.) Auscultate each side and compare findings. B.) Document the findings in the client's medical record. C.) Ask the client to take slow breaths through his/her nose. D.) Use the diaphragm of the stethoscope to listen to lung sounds. E.) Listen to inspiration on one side and expiration on the other side.

A.) Skin D.) Nails E.) Hair [Pg. 508]

Which are included as parts of the assessment of the integumentary system? Select all that apply. A.) Skin B.) Hands C.) Ears D.) Nails E.) Hair

A.) Assessment of support systems B.) Limiting position changes to make the exam less taxing D.) Stiff muscles and joints making positioning difficult F.) Adapting techniques to accommodate decreased vision and hearing abilities [Pg. 507]

Which are nursing considerations when performing a physical assessment on an elderly client? Select all that apply. A.) Assessment of support systems B.) Limiting position changes to make the exam less taxing C.) More client cooperation, since the client has been assessed before D.) Stiff muscles and joints making positioning difficult E.) Limited ability to comprehend F.) Adapting techniques to accommodate decreased vision and hearing abilities

A.) Eyes B.) Ears E.) Throat "HEENT is helpful in remembering all the components of an assessment of the head" H - Head E - Ears E - Eyes N - Nose T - Throat

Which are parts of the assessment of the head? Select all that apply. A.) Eyes B.) Ears C.) Hair D.) Mouth E.) Throat

A.) To obtain baseline information B.) To develop a plan for nursing care C.) To evaluate effectiveness of interventions [Pg. 500]

Which are reasons for a nurse to perform a nursing assessment of a client? Select all that apply. A.) To obtain baseline information B.) To develop a plan for nursing care C.) To evaluate effectiveness of interventions D.) To receive reimbursement for services provided E.) To determine the presence of disease and its pathology

A.) Eyes [Pg. 597]

Assessment of cranial nerve II is part of which assessment? A.) Eyes B.) Hearing C.) Speech D.) Swallowing

A.) Pregnant clients C.) Athletes D.) Growing children [Pg. 508]

Calculating the body mass index (BMI) is typically part of a physical assessment. For which types of clients is the BMI not helpful? Select all that apply. A.) Pregnant clients B.) Very overweight clients C.) Athletes D.) Growing children E.) Mature adults seeking help in losing weight

A.) Inspection [Pg. 503 - 506]

The nurse is assessing the abdomen for a client returning from an abdominal surgery. Which assessment technique should the nurse perform first? A.) Inspection B.) Auscultation C.) Palpation D.) Percussion

D.) Palpate the carotid arteries simultaneously.

The nurse is assessing the cardiovascular status of a client including pulses. Which action made by the nurse can place the client at risk for a stroke? A.) Auscultate the carotids for bruits. B.) Have the client lay on the left side. C.) Locate and feel pulses with the thumbs. D.) Palpate the carotid arteries simultaneously.

A.) Have the client cough and listen again.

The nurse is assessing the lungs of a client and notes slight crackles as well as regular breath sounds in both lung fields. The client appears to be in no respiratory distress and has an oxygen saturation of 98% on room air. What should be the nurse's first intervention? A.) Have the client cough and listen again. B.) Notify the primary health care provider. C.) Administer a nebulizer breathing treatment. D.) Document the findings in the medical record.

C.) Abdominal muscular rigidity [Pg. 584]

The nurse is assigned to care for a client admitted with a perforated diverticulum and developed peritonitis. Which abdominal assessment finding would the nurse expect to find?. A.) Hyperactive bowel sounds B.) Tympany during percussion C.) Abdominal muscular rigidity D.) Soft and rounded abdomen

B.) Press in the abdomen and slowly release. [Pg. 585] "Check for rebound tenderness: Place your hand perpendicular to the abdomen. Press firmly and slowly then release quickly"

The nurse is caring for a young adult who presents to the emergency room with severe abdominal pain in the right lower quadrant. Which assessment technique should the nurse use to determine rebound tenderness?A.) Inspect the abdomen for distension. B.) Press in the abdomen and slowly release. C.) Auscultate all four abdominal quadrants. D.) Percuss the abdominal area for hyperresonance.

All are correct [Pg. 506] "Infants usually feel most secure if a parent holds them during the examination, either against the chest or, for older infants who can sit without support, on the parent's lap. Otherwise position an infant on a padded examination table." [Pg. 506] "Combat fears by demonstrating the procedure on a doll or having the part step on the scale before you approach the child." [Pg. 506] "Develop rapport by asking the child about his favorite school or play activities." [Pg. 507] "Provide privacy. Adolescents often worry about the "normalcy" of their changing bodies and appreciate respect for their privacy." [Pg. 507] "Assess the client's support system and ability to perform activities of daily living."

The nurse is considering modifications to the physical exam for various age groups. Which would be appropriate considerations? Select all that apply. A.) Have a parent hold the infant. B.) Demonstrate the procedure on the preschooler's doll first. C.) Develop rapport with the school-age child. D.) Provide privacy for the adolescent. E.) Assess the older adult's ability to perform activities of daily living.

A.) Auscultation B.) Inspection C.) Percussion E.) Palpation [Pg. 503 - 506] Olfaction is also one "the use of the sense of smell to gather data"

The nurse is teaching a group of students the components of a physical examination. What should be included in the discussion? Select all that apply. A.) Auscultation B.) Inspection C.) Percussion D.) Transmission E.) Palpation

B.) Mental status C.) Physical status D.) Cultural status F.) Socioeconomic status [Pg. 500 - 502]

Which areas should the nurse include when performing a health assessment? Select all that apply. A.) Family status B.) Mental status C.) Physical status D.) Cultural status E.) Employment status F.) Socioeconomic status

D.) The Denver Developmental Test [Pg. 519]

Which assessment tool(s) should the nurse use to assess the neuromuscular status of a 5-year-old child?. A.) The Romberg Test B.) The Glasgow Coma Scale C.) The Weber and Rinne Tests D.) The Denver Developmental Test

A.) Active range of motion B.) Passive range of motion E.) Applying resistance [Pg. 518]

Which assessments are done as part of assessment of joint mobility and muscle function? Select all that apply A.) Active range of motion B.) Passive range of motion C.) Gait D.) Balance E.) Applying resistance

B.) Vibration from a tuning fork louder in one ear than the other

Which indicates a positive Weber test? A.) Drooping of the eyelid B.) Vibration from a tuning fork louder in one ear than the other C.) Loss of balance when standing on one leg with eyes closed D.) Vibration from a tuning fork cannot be heard clearly when the fork is placed on a bony surface behind the ear

A.) "What is your name?" B.) "What is the date?" E.) "Who is the president?"

Which questions are used to determine the orientation of a client who is hospitalized? Select all that apply A.) "What is your name?" B.) "What is the date?" C.) "What is your diagnosis?" D.) "Who is your doctor?" E.) "Who is the president?"

B.) Tympany [Pg. 583]

Which sound would the nurse expect to hear during percussion of a full bladder? A.) Dullness B.) Tympany C.) Resonant D.) Hyperresonant

B.) Give praise freely. C.) Perform any invasive procedures at the end of the exam. E.) Include the parents in the assessment.

Which would be important nursing considerations when performing a physical assessment on a toddler? Select all that apply. A.) Parents should be kept out of the room during the assessment. B.) Give praise freely. C.) Perform any invasive procedures at the end of the exam. D.) Be firm and do not allow the child to make choices. E.) Include the parents in the assessment.

Clearer Auscutation [Pg. 576] "The cardiac assessment should include three positions: sitting, supine, and left lateral recumbent. Each position brings the heart nearer to the chest wall, improving the sounds heard. Additional cardiac assessments should include the evaluation of the carotid arteries, jugular veins, and peripheral vessels." [Davis Advantage]

Why is it important for the client to change positions during the assessment of the heart?

A - Asymmetry B - Border irregularity C- Color variation D - Diameter greater than 0.5cm E - Elevation above skin surface [Pg. 510]

You can remember the warning signs of malignant lesions by thinking of the letters ABCDE.