PrepU ch.3 objective data: physical exam
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. -Nasopharyngeal airway -Gloves -Gown -Face shield -Stethoscope
-Gloves -Gown -Face shield Explanation: The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 33. Chapter 3: Collecting Objective Data: The Physical Examination - Page 33
Which is an example of palpation? Select all that apply. -The nurse detects a small mass in the epigastric area. -The nurse detects crepitus over the individual's thorax. -The nurse detects increased warmth surrounding an abdominal incision. -The nurse detects fruity odor of the client's breath. -The nurse detects dullness over the liver.
-The nurse detects a small mass in the epigastric area. -The nurse detects crepitus over the individual's thorax. -The nurse detects increased warmth surrounding an abdominal incision. Explanation: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 37. Chapter 3: Collecting Objective Data: The Physical Examination - Page 37
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? a.Light palpation b.Moderate palpation c.Deep palpation d.Bimanual palpation
a. Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 40. Chapter 3: Collecting Objective Data: The Physical Examination - Page 40
What would be the expected tone elicited by percussion of a normal lung? a.Resonance b.Hyper-resonance c.Tympany d.Dullness
a. Resonance Explanation: Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 42. Chapter 3: Collecting Objective Data: The Physical Examination - Page 42
What is used to gauge central and peripheral nervous system disorders? a.Strength of a reflex b.Gait c.Tuning fork d.Heat and cold
a. Strength of a reflex Explanation: The strength of a reflex is used to gauge central and peripheral nervous system disorders. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 33. Chapter 3: Collecting Objective Data: The Physical Examination - Page 33
Which describes the nurse using the technique of percussion? a.The nurse notes resonance over the individual's thorax. b.The nurse detects crepitus over the individual's thorax. c.The nurse notes symmetry of the individual's thorax. d.The nurse detects rustling over the individual's thorax.
a. The nurse notes resonance over the individual's thorax. Explanation: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 42. Chapter 3: Collecting Objective Data: The Physical Examination - Page 42
The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching? a.Cover your nose and mouth with your hands when coughing or sneezing b.Dispose of tissues directly into trash cans c.Wash your hands before coming into contact with another person d.Take medicine when you cannot stop coughing
b. Dispose of tissues directly into trash cans Explanation: Clients and other people with symptoms of a respiratory infection are asked to cover their mouths/noses when coughing or sneezing, but not covering the nose and mouth with their hands. Additionally, clients should dispose of tissues directly into trash cans and perform hand hygiene after hands have been in contact with respiratory secretions. The nurse does not teach to use hands to cover the face when sneezing or coughing—the client should instead cough or sneeze into a sleeve. Washing hands before coming into contact with another person is not part of client teaching for a person with pneumonia. Taking medicine when you cannot stop coughing does not answer the question. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 35. Chapter 3: Collecting Objective Data: The Physical Examination - Page 35
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? a.Supine b.Lithotomy c.Standing d.Prone
b. Lithotomy Explanation: The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client lying on her back with the hips at the edge of the examination table and the feet supported by stirrups. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the standing position, the client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 40. Chapter 3: Collecting Objective Data: The Physical Examination - Page 40
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? a.Inspection b.Palpation c.Percussion d.Auscultation
b. Palpation Explanation: Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 37. Chapter 3: Collecting Objective Data: The Physical Examination - Page 37
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 Explanation: Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 42. Chapter 3: Collecting Objective Data: The Physical Examination - Page 42
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? a.One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. b.The middle finger of one hand is placed on the body surface and the other middle finger strikes. c.The ulnar surface of one hand is placed against the body surface and vibrations are felt. d.One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.
b. The middle finger of one hand is placed on the body surface and the other middle finger strikes. Explanation: Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, pp. 41-42. Chapter 3: Collecting Objective Data: The Physical Examination - Page 41-42
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? a.Warm, comfortable room b.Quiet area free of disturbance c.Adequate lighting d.Firm examination bed or table
c. Adequate lighting Explanation: Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 32. Chapter 3: Collecting Objective Data: The Physical Examination - Page 32
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? a.Nonantimicrobial soap and water with friction b.Hand wash with antiseptic soap c.Application of an alcohol-based hand rub d.No washing is needed because hands are not soiled.
c. Application of an alcohol-based hand rub Explanation: The nurse can apply an antiseptic hand rub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 34. Chapter 3: Collecting Objective Data: The Physical Examination - Page 34
A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this client's anxiety? a.Have him urinate before the examination. b.Perform the genital assessment first to get it over with. c.Before performing each procedure, explain what it involves and its purpose. d.Have him undress and put on an examination gown.
c. Before performing each procedure, explain what it involves and its purpose. Explanation: Throughout the examination, continue to explain what procedure you are performing and why you are performing it. This helps to ease your client's anxiety. If a urine sample is not necessary, ask the client to urinate before the examination to promote an easier and more comfortable examination of the abdomen and genital areas, although it will not likely ease the client's anxiety. Begin the examination with the less intrusive procedures such as measuring the client's temperature, pulse, blood pressure, height, and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with you and help to ease client anxiety about the examination. Having the client undress and put on an examination gown, although required, is not likely to ease his anxiety. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 37. Chapter 3: Collecting Objective Data: The Physical Examination - Page 37
Universal precautions are primarily designed to protect the health care worker from what? a.STDs b.Musculoskeletal injuries c.Blood-borne pathogens d.Respiratory diseases
c. Blood-borne pathogens Explanation: Universal precautions are a set of guidelines designed to prevent transmission of HIV, hepatitis B virus, and other blood-borne pathogens when providing first aid or health care. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 36. Chapter 3: Collecting Objective Data: The Physical Examination - Page 36
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.Hyperresonant d.Flat
c. Hyperresonant Explanation: A hyperresonant lung sound is very loud, low in pitch, long in duration, and booming in quality. This is the sound heard from emphysematous lungs. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 42. Chapter 3: Collecting Objective Data: The Physical Examination - Page 42
You should use the bell of the stethoscope when auscultating what type of sounds? a.Abnormal sounds b.High-frequency sounds c.Low-frequency sounds d.Sounds that are partially audible without a stethoscope
c. Low-frequency sounds Explanation: The bell is used with light skin contact to hear low-frequency sounds. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 43. Chapter 3: Collecting Objective Data: The Physical Examination - Page 43
Which action by a nurse demonstrates the correct application of the principles of standard precautions? a.Using an antiseptic hand scrub to cleanse visibly soiled hands. b.Wearing a gown, gloves, and mask for the physical exam c.Wearing gloves when palpating the tongue, lips, & gums d.Change gloves after each body area is examined
c. Wearing gloves when palpating the tongue, lips, & gums Explanation: The nurse should wear gloves when examining or touching any areas where there is the potential for exposure to blood or body fluids. Gloves are changed between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Wearing a gown, gloves, and mask is not necessary for the entire physical assessment. If hands are visibly soiled, the nurse should wash with soap and water. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 36. Chapter 3: Collecting Objective Data: The Physical Examination - Page 36
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... a.light palpation. b.moderate palpation. c.deep palpation. d.very deep palpation.
c. deep palpation. Explanation: Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 40. Chapter 3: Collecting Objective Data: The Physical Examination - Page 40
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? a.Reflex hammer b.Tuning fork c.Tongue depressor d.Coin or key
d. Coin or key Explanation: The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 33. Chapter 3: Collecting Objective Data: The Physical Examination - Page 33
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? a.Bowel b.Normal heart c.Breath d.Heart murmur
d. Heart murmur Explanation: The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 43. Chapter 3: Collecting Objective Data: The Physical Examination - Page 43
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? a.Auscultation, percussion, palpation, inspection b.Percussion, palpation, inspection, auscultation c.Palpation, inspection, auscultation, percussion d.Inspection, palpation, percussion, auscultation
d. Inspection, palpation, percussion, auscultation Explanation: Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 37. Chapter 3: Collecting Objective Data: The Physical Examination - Page 37
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 Explanation: Skinfold calipers measure skinfold thickness of subcutaneous tissue to aid in establishing a client's percent body fat. A platform scale with height attachment measures height and weight. A metric ruler is used to measure the size of skin lesions. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 3: Collecting Objective Data: The Physical Examination, p. 32. Chapter 3: Collecting Objective Data: The Physical Examination - Page 32
