chapter 3 jensen

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?

palmar surface

palm of hand

part of hand best for palpation of abdominal assessment

finger pads

part of hand used for palpation of fine discrimination. (pulse, lymph nodes, small lumps, and edema)

palmar surface of fingers

part of hand used for palpation used for assessing firmness, contour, position, size, pain, and tenderness.

To adhere to standard precautions, the nurse should remember to (Select all that apply.)

-wash hands before and after patient contact -change white coat frequently

fingernails should be

1/4 inch or less

otoscope

A device used to look into the ears

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.

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

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

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

Inspection, palpation, percussion, auscultation

Auscultation

Listening with a stethoscope

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 must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

When conducting a health assessment, it is sometimes necessary to conduct specific physical assessments that use specialized tools. What are some of these special tools? Select all that apply.

Ophthalmoscope Goniometer Skin-fold calipers

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

Skin lesion size

T/F The stethoscope should be directly on the skin

True

The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?

Use the middle finger to deliver two taps

The nurse is caring for the patient who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the patient

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

moderate palpation

assessing abdominal characteristics; palpating 1-2 cm

light palpation

assessing skin texture; palpating 1 cm

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing

blunt percussion

the quietest percussion sounds are over

bones

reflex hammer

designed to test neurological responses of the deep tendons to assess for abnormalities of the central or peripheral nervous system.

Bell of stethoscope

detects low pitched heart murmurs

Diaphragm of stethoscope

detects most sounds; lung and heart

Tympany is a percussion sound commonly located in the A. Thorax B. Upper arm C. Abdomen D. Lower leg

c. abdomen

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

T/F 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

inspection

general observation of the patient as a whole

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?

goniometer

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

goniometer

which organs or body areas does the nurse auscultate as part of the admitting assessment?

heart, lungs, abdomen.

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.

otoscope

instrument used for visual examination of the ear

opthalmoscope

instrument used to examine the interior of the eye

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?

knee-chest

the patient is complaining of abdominal pain. what technique is used to form an overall impression?

light palpation

tympanic

loud, high, moderate, drum-like sound

resonant

loud, low, long, hollow sound

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

lungs

dorsal recumbent

lying on back with legs bent and feet flat

heart sounds

moderate low lub-dub, rhythmic 60-100/min anterior thorax

dull

moderate, high, thud sound

latex allergy

most common in nurses and patients more frequently hospitalized

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 environmental noise

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

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

risk for injury

For which assessment would the nurse plan to use direct percussion?

sinuses

vesicular lung sounds

soft low pitch rustling, wispy 12-20/min anterior and posterior thorax

blood pressure

soft to loud high pitch swooshing or knocking 60-100/min arm

abdominal sounds

soft to loud high pitch gurgly, intermittent 5-35/min. abdomen

flat

soft, high, short, dull sound

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?

stethoscope bell

indirect percussion

tap finger or hand placed over body surface

percussion

tapping on the patient to produce sound or elicit tenderness

direct percussion

taps fingers directly on skin

hand hygiene

the most important technique used in preventing and controlling transmission of infection

palpation

to examine by touch

T/F standard precautions are used on every patient because it is not always known if they are infected

true

The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain?

tuning fork

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

up and back

skinfold calipers

used to measure percent body fat

Hyperresonant

very loud, low, long, booming sound