Physical Assessment Ch. 1-4

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use? a. Focused b. Assessment flow chart c. Progress notes d. Nursing minimum data set

a. Focused

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a. physiologic status. b. holistic wellness status. c. developmental history. d. level of functioning.

a. physiologic status.

A health care provider 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 student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs? a. Resonant b. Tympanic c. Hyperesonant d. Flat

c. Hyperesonant

Why is accurate and effective documentation most important? a. It keeps clients informed about their care b. Documentation constitutes a legal record. c. It ensures that data can be used for research purposes. d. It can be used to educate other nurses.

b. Documentation constitutes a legal record.

What would be the expected tone elicited by percussion of a normal lung? a. Resonance b. Hyper-resonance c. Tympany d. Dullness

a. Resonance

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) a. ongoing or partial assessment. b. focused or problem-oriented assessment. c. emergency assessment. d. initial comprehensive assessment.

b. focused or problem-oriented assessment

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? a. Reflex hammer b. Skinfold calipers c. Flexible metric measuring tape d. Goniometer

d. Goniometer

The ulnar edge of the hand is highly receptive to which of the following sensations? a. Moisture and contour b. Vibrations and moisture c. Contour and temperature d. Temperature and vibrations

d. Temperature and vibrations

A nurse manager is making rounds in the hospital unit. Which of the following actions would require the nurse manager to intervene if observed? a. A nurse charts "liver palpation normal." b. An unlicensed assistive personnel (UAP) charts a client's vital signs several minutes after taking them. c. A nurse documents wound care 20 minutes after performing the care. d. An unlicensed assistive personnel (UAP) documents completion of activities of daily living (ADLs) for several clients.

a. A nurse charts "liver palpation normal."

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015? a. Evidence of validation of all vital sign measurements b. Meaningful use of electronic health records c. Data backup of all digital files d. Use of a standard method of data communication

a. Evidence of validation of all vital sign measurements

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: a. Limiting abbreviations to those approved for use by the institution. b. Using only abbreviations whose meaning is self-evident to an educated health professional. c. Ensuring that abbreviations are understandable to clients who may seek access to their health records. d. Using only those abbreviations that are defined in full at another location in the client's chart.

a. Limiting abbreviations to those approved for use by the institution.

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? a. Measure the client's vital signs, height, and weight b. Begin at the head and move in a systematic approach. c. Auscultate all necessary body systems to prevent disturbing any organs. d. Allow the client to undress and put on a gown.

a. 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? a. Ophthalmoscope b. Tuning fork c. Otoscope d. Penlight

a. Ophthalmoscope

For which assessment would the nurse plan to use direct percussion? a. Sinuses b. Kidneys c. Liver d. Gallbladder

a. Sinuses

A client has been prescribed a new medication. What action is most important for the nurse to take prior to administration? a. Verify client allergies to medications. b. Clarify order with the health care provider. c. Assess client laboratory results. d. Assess client's vital signs prior to administration.

a. Verify client allergies to medications.

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? a. Wood's light b. Penlight c. Magnifying glass d. Examination light

a. Wood's light

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to a. allow the client to verbalize his or her feelings. b. offer reasons why the client should not feel angry. c. provide structure during the interview. d. refer the client to a different health care provider.

a. allow the client to verbalize his or her feelings.

During an interview, how can the nurse best assist the client as the client tells his or her story? a. interrupting only if absolutely necessary b. using a focused questioning format c. correcting the client when he or she makes erroneous statements d. suggesting information the client has appeared to have forgotten

a. interrupting only if absolutely necessary

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? a. Ask the client to identify which medications taken every day. b. Ask the client to bring all the medications and supplements to an interview. c. Ask the caregiver whether the client is taking prescribed medications. d. Ask the client about the use of any over-the-counter medications.

b. Ask the client to bring all the medications and supplements to an interview.

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? a. Hyper-resonance b. Resonance c. Tympany d. Dullness

b. Resonance

The nurse is providing care to a client who has had a significant change in their vital signs and worsening symptoms. How should the nurse communicate these new findings to the health care provider? a. Complete an ongoing assessment form. b. Use the SBAR model. c. Use the COLDSPA model. d. Write a narrative progress note.

b. Use the SBAR model.

A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called a. pie charting b. charting by exception c. narrative charting d. batch charting

b. charting by exception

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? a. Cluster client cues. b. Evaluate outcome. c. Identify client concerns. d. Implement an intervention.

b. evaluate outcome

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

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event? a. "Client visibly agitated during assessment and unwilling to continue." b. "Client became upset and terminated assessment." c. "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." d. "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

c. "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

Which of the following examples of documentation best exemplifies sound clinical documentation practices? a. "Client is anxious during questioning regarding health history and family history." b. "Abnormal chest sounds noted during posterior chest auscultation." c. "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." d. "Client reports sharp pain to chest on deep inspiration."

c. "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

A nurse is working with a woman who has been abused by her husband. Which of the following is a physiological sign commonly associated with abuse? a. High blood sugar b. Decreased respiration rate c. Hypertension d. Decreased heart rate

c. Hypertension

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? a. It maximizes compliance with standards of documentation. b. It disables the graphing of trends in vital signs or assessment data. c. It allows several health team members to view the client record simultaneously. d. It automatically corrects both spelling and grammar.

c. It allows several health team members to view the client record simultaneously.

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments? a. "Nurses focus on the diagnosis and treatment of diseases." b. "Both are the same and they serve to validate the information collected." c. "Nurses focus on the diagnosis of actual human responses to disease or life events." d. "The health care provider focuses on the treatment of human responses caused by diseases."

c. Nurses focus on the diagnosis of actual human responses to disease or life events.

What are nurses able to detect through the health assessment? a. Areas that need continuous care b. Areas that need in-hospital care c. Areas that need referral to a specialist d. Areas in need of health adjustments

d. Areas in need of health adjustments

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? a. Safety among client populations decreases b. Pharmacy orders are electronically verified c. Physician notes are more secure d. Client safety increases

d. Client safety increases

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? a. It documents assessments on separate forms. b. It records progress under problems, interventions, and evaluation. c. It provides and refers to client's problem by a number. d. It provides quick access to abnormal findings.

d. It provides quick access to abnormal findings.

A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use? a. Open-ended forms b. Cued or checklist forms c. Integrated cued checklist d. Nursing minimum data set

d. Nursing minimum data set

A nurse is preparing to 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? a. Platform scale with height attachment b. Metric ruler c. Sphygmomanometer d. Skinfold calipers

d. Skinfold calipers

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms? a. yes-or-no questions to determine relevant areas of the physical examination b. specific questions to secure a description of every symptom c. pertinent positive and negative questions to determine relevant details d. open-ended questions to allow full freedom of response

d. open-ended questions to allow full freedom of response

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using a. inspection. b. palpation. c. Doppler magnification. d. percussion.

d. percussion.