Chapter 3: Collecting Objective Data: The Physical Examination

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

Blood-borne pathogens

A nurse is preparing to evaluate an older 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 student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Consult with a clinical instructor.

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

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

Dorsal surface

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.

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 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

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

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

Light palpation

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

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

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

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

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 student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed?

The bell of the stethoscope is used to auscultate bowel sounds.

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 percussion?

The nurse notes resonance over the individual's thorax.

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

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

Up and back

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

When hands are visibly soiled After removing gloves After providing mouth care After taking the blood pressure of a client with intact skin

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart using the stethoscope bell

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 nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?

color

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

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

dorsal surface of the hand

A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?

explain to the client why the assessment is important and the possibility of missing important findings.

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

Light palpation is most appropriate to assess the

inflamed areas of skin Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).

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

low-frequency sounds

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