NURS 212 -- Chapter 3 PrepU Review

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.

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?

percussion

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

percussion.

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

Gloves, mask, protective eye goggles, gown

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.

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

Light palpation

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

Low-frequency sounds

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

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 auscultation?

The nurse detects gurgling throughout the abdomen.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland

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

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

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

c, d, e, b, a

A client who reports having a burning rash in the perianal area says, "Just stop asking questions and look at the rash right now." Which response by the nurse is best?

"I just need to gather more information about your symptoms to help you the best way I can."

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

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.

-Gloves -Gown -Face shield

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

-Inspection -Palpation -Auscultation

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

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

For which of the following assessments would the nurse plan to use light palpation?

-Skin temperature -Skin texture -Skin rash

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

-The nurse notes a fine rash covering the individual's thorax. -The nurse notes symmetry of the individual's thorax. -The nurse detects foul odor of the urine.

For which patient should the nurse wear gloves to provide care? Select all that apply.

-The patient with Clostridium difficile -The patient with vancomycin-resistant enterococci -The patient requiring oropharyngeal suctioning

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

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

Balance

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

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?

Braden scale

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

Coin or key

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?

Cranial nerves

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

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

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

Dorsal surface

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

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

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

Examining the tongue

When assessing pulses, the nurse would use which part of the hand for palpation?

Fingerpads

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

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?

Heart murmur

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?

Hyperresonant

When you observe the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing?

Inspecting

What assessment technique is performed for every body part and body system?

Inspection

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?

Inspection, palpation, percussion, auscultation

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

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

Lower pitched

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?

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

Your lab instructor explains that physical examination relies on what cardinal assessment technique?

Percussion

What would be the expected tone elicited by percussion of a normal lung?

Resonance

For which assessment would the nurse plan to use direct percussion?

Sinuses

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?

Skinfold calipers

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

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations

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?

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

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

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

True

A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound?

Tympany

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

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

Wearing gloves when palpating the tongue, lips, & gums

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

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

bone.

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

dorsal surface of the hand.

Light palpation is most appropriate to assess the

inflamed areas of skin

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

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

use as a drape

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

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment.

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

blunt percussion.

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? blunt percussion.

Light

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

Limit position changes as much as possible

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

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.

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.

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

palpation

You are performing a shift assessment as you begin caring for one of your patients. What is the most effective assessment technique for the lymph nodes of the neck?

Palpation

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.

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

When should the nurse perform hand washing? Select all that apply.

-When hands are visibly soiled -After removing gloves -After providing mouth care

When should the nurse wear gloves? Select all that apply.

-When touching blood or body fluids -In anticipation of body fluid contact

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

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

For which assessment would the nurse plan to use light palpation?

Papular rash

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

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?

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

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

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?

Lithotomy

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?

Palpation

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 all environmental noise.

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

For which assessment would the nurse plan to use deep palpation?

Size of liver

What is the nurse's primary role in subjective data collection?

To improve the client's health status