The Point Ch.3
Answer: B To check the client's distant vision the nurse should use the Snellen chart, An ophthalmoscope is used to view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A penlight is used to test pupillary constriction.
A client with an inability to ready billboards while driving arrives at the health car facility for an eye examination. Which piece of equipment should the nurse use to check the clients distant vision? A) Penlight B) Snellen chart C) Ophthalmoscope D) Opaque card
Answer: A
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) Adequate lighting B) Firm examination C) Quiet area free of disturbance D) Warm, comfortable room
Answer: A
A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristic can the nurse observe by using inspection? A) Color B) Temperature C) Texture D) Elasticity
Answer: A, C, E
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. A) Readjusting the earpieces to ensure a snug fit. B) Tell the client to hold the breath C) Angle the binaurals towards the nose D) Place the diaphragm against the client's clothing E) Eliminate distracting noises from the environment
Answer: D Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.
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) Percussion, palpation, inspection, auscultation B) Palpation, inspection, auscultation, percussion C) Auscultation, percussion, palpation, inspection D) Inspection, palpation, percussion, auscultation
Answer: D
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? A) Using the diaphragm to listen to low-pitched sounds B) Using the bell to detect high-pitched sounds C) Application of firm pressure when using the bell D) Ensuring that contact with the skin is maintained
Answer: B A wood's light is a special piece of examination equipment that is used to test for fungus. A penlight for more general assessments, such as of the mouth and throat and to trans illuminate the sinuses. A magnifying glass is used to enlarge the visibility of a lesion. An examination light is used better illuminate the client's body as a whole to facilitate physical examination.
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) Magnifying glass B) Wood's light C) Penlight D) Examination light
Answer: A
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 earwax 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? A) Otoscope B) Stethoscope C) Sphygmomanometer D) Ophthalmoscope
Answer: A
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? A) Palmar surface B) Fingertips C) Dorsal surface D) Fingerpads
Answer: A
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) The middle finger of one hand is placed on the body surface and the other middle finger strikes. B) One to two fingers are placed over the body structure and the fingertips are used to tap the skin. C) The ulnar surface of one hand is placed against the body surface and vibrations felt. D) One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.
Answer: C
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) Tympany C) Resonance D) Dullness
Answer: D
A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound? A) Hyper-resonance B) Resonance C) Dullness D) Tympany
Answer: D The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client laying on her back with the hips at the edge of the examination table and the feet supported by stirrups.
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) Prone B) Standing C) Supine D) Lithotomy
Answer: D
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 patient's anxiety? A) Perform the genital assessment first to get it over with. B) Have him urinate before the examination. C) Have him undress and put on an examination gown. D) Before performing each procedure, explain what it involves and its purpose.
Answer: D Sterognosis is the ability to recognize objects by touch.
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? A) Tongue depressor B) Tuning fork C) Reflex hammer D) Coin or key
Answer: C
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? A) Compare appearance of symmetric body parts B) Use good lighting, preferably sunlight C) Eliminates distracting noises from the environment D) Look and observe before touching the client
Answer: D
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) Auscultate all necessary body systems to prevent disturbing any organs. B) Begin at the head and move in a systemic approach C) Allow the client to undress and put on a gown. D) Measure the client's vital signs, height, and weight.
Answer: D
A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination? A) Remove gloves only after examination is over B) Recap used needles and place in puncture-resistant containers C) Approach the client from the left side of the examination table D) Wash hands before examination in the examination room
Answer: B
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? A)Prone B) Knee-chest C) Dorsal recumbent D) Supine
Answer: A The prone position places the client on the abdomen with the head to the side. This position is used primarily to assess the nip joint.
A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination? A) Prone B) Supine C) Dorsal recumbent D) Standing
Answer: B
A nurse needs to auscultate the heart sounds of a patient who is in a hospital room watching his favorite television show. Before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment? A) Leave the television as is, as the client is enjoying his show and being distracted from his pain. B) Ask the client if it would be okay to mute the volume on the TV during the assessment. C) Turn off the TV and begin the assessment. D) Ask the client to play some music from his laptop computer instead of watching TV.
Answer: C A goniometer is a device used for measuring the degree of flexion and extension available at a joint.
A nurse needs to measure the degree of flexion and extension that a student athlete 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) Flexible metric measuring tape B) Reflex hammer C) Goniometer D) Skinfold calipers
Answer: C
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? A) Deep palpation B) Moderate palpation C) Light palpation D) Bimanual palpation
Answer: B
A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following? A) Lie down, with knees bent, legs separated, and feet flat on the table B) Lie on the back with legs together on the examination table C) Place the chest and abdomen on the table with head to the side D) Kneel on the table with the weight of the body supported by the chest and knees
Answer: C 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, and bowel sounds.
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) Normal heartbeat B) Breath C) Heart murmur D) Bowel
Answer: B
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? A) Gloves, gown B) Gloves, mask, protective eye goggles, gown C) Mask, protective eye goggles D) Mask, protective eye goggles, gown
Answer: A
A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for the student to gain confidence in assessment skills? A) Practice performing a physical examination on a classmate, friend, or relative. B) Talk with a counselor about fears and learn strategies for managing anxiety. C) Reread a nursing textbook an assessment and study the illustrations. D) Watch videos on the internet of nurses performing physical examinations.
Answer: D
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) No washing is needed because hands are not soiled C) Hand wash with antiseptic soap D) Application of an alcohol-based hand rub
Answer: A
Which action by a nurse demonstrates the correct application of the principles of standard precautions? A) Wearing gloves when palpating the tongue, lips, and gums B) Using an antiseptic hand scrub to cleanse visibly soiled hands C) Wearing a gown, gloves, and mask for the physical exam D) Changing gloves after each body area is examined
Answer: A
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? A) To determine whether a structure is filled with air of fluid or is a solid structure B) To feel for deep organs or structures covered by thick muscles C) To determine tenderness, moisture, and the surface skin texture D) To observe for abnormalities on the skin's surface
