Collecting Objective Data: The Physical Examination ch 3

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

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 physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight.

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

alcohol-based rub

A nurse is preparing to evaluate an elderly 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

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 would use the tuning fork to assess for what?

hearing loss

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

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

light

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?

lithotomy

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

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

palpation

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

resonance

What is the nurse's primary role in subjective data collection?

to improve the clients health status

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

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone

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.

breasts, chest and thorax, cardiovascular, groin hips and knees, then shins and ankles

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

dorsal surface

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

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

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

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

low-frequency sounds

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

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