PrepU ch. 3

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

When performing a physical assessment on an older adult client, what should the nurse consider offering this client?

An extra blanket

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, non-intact 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 antiseptic hand rub

The nurse is planning to assess for the presence of lower pitch sounds when examining a client's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

A nurse is preparing to perform a test for stereognosis (ability to perceive objects by touch) in a client. Which piece of equipment should the nurse use?

Coin or key

A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam?

Collect necessary equipment essential to the exam.

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

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 information?

Dorsal hand surface

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

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown

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 female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate?

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

The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.

False- should be high pitched

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?

Fungal infection

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

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

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?

Heart sounds

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?

Hyperresonant

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

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

Latex allergy

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

Light palpation

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

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

For which assessment would the nurse plan to use indirect percussion? Select all that apply.

Liver, gallbladder, kidneys

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

Low-frequency sounds

A 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 is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?

Otoscope

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

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

Percussion

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

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

Resonance

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 client. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

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?

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

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

The diaphragm should be held firmly against the body part.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client'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 palpation?

The nurse notes increased warmth surrounding an abdominal incision.

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

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

Up and back

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 is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?

goniometer

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

indirect percussion

Light palpation is most appropriate to assess the

inflamed areas of skin

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

inspection

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

palpation

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?

reflex hammer

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

While performing a physical examination on an older adult, the nurse should plan to

use minimal position changes