HA - Chapter 3: Collecting Objective Data: The Physical Examination

The correct depth for light palpation is:

1 cm When performing light palpation, you should depress the patient's skin surface no more than 1 cm.

The nurse would use the tuning fork to assess for what? Hearing loss Eye movement Visualization Reflexes

Hearing loss The tuning fork is used to assess for hearing loss. Reflexes may be checked with a reflex hammer. An ophthalmoscope is used for the eye. An ophthalmoscope and otoscope are used for visualization.

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 diaphragm of the stethoscope is used to auscultate normal heart sounds. The bell of the stethoscope is used to auscultate bowel sounds. The diaphragm of the stethoscope is pressed firmly to the client's back when auscultating lung sounds. The bell of the stethoscope is pressed lightly against the skin to identify murmurs and extra heart sounds.

The bell of the stethoscope is used to auscultate bowel sounds. The diaphragm, not the bell, of the stethoscope is used to assess bowel sounds. The diaphragm of the stethoscope is used to hear low-pitched sounds (normal heart sounds) and should be held firmly to the skin, whereas the bell of the stethoscope is used to detect high-pitched sounds (such as murmurs and extra heart sounds) and is held lightly to the skin.

What palpation category does this description fall under: Depressing the palmar surface of your fingers 1 to 2 cm deep into the surface structure in order to assess firmness, contour, position, size, pain, and tenderness of the structure?

Moderate palpation Correct! Moderate palpation involves depressing the skin surface 1 to 2 cm with the dominant hand and using a circular motion to feel for easily palpable body organs and masses.

When performing blunt percussion during an assessment, you should begin by:

Placing your palm flat against the patient's skin When performing blunt percussion, you put the palm of your nondominant hand against the patient and then strike it with the closed fist of your other hand. Direct percussion involves tapping one or two fingers on the patient's skin. Indirect percussion begins with placing the middle finger of your nondominant hand on the surface to be assessed.

Which is an example of auscultation? Select all that apply. The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse notes hyperresonance over the client's thorax. The nurse detects tympany over the client's lower abdomen.

The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the client's anterior thorax. Auscultation is used by the nurse to assess the lub-dub sounds of the heart, lung sounds, such as rustling, and gurgling bowel sounds. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as hyperresonance over the lungs and tympanic sounds over the bowel.

Which describes the nurse using the technique of palpation? The nurse notes increased warmth surrounding an abdominal incision. The nurse notes asymmetry of the individual's abdomen. The nurse notes gurgling sounds over the individual's abdomen. The nurse notes tympany over the individual's lower abdomen.

The nurse notes increased warmth surrounding an abdominal incision. The nurse uses palpation to assess the individual through touch, such as to detect increased warmth surrounding an incision. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting the symmetry of the abdomen. Auscultation is used by the nurse to assess bowel sounds. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

When percussing over dense tissue or bone, the nurse will hear flatness. Describe what flatness sounds like.

A soft-volume, high-pitched sound Flatness is soft in volume and high-pitched.

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? Inspection Palpation Percussion Auscultation

Palpation 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.

what can be gathered during inspection

Inspection addresses many parts of the general survey, including respiratory rate, gait, and speech. A patient's temperature, blood pressure, and heart rate cannot be determined by inspection alone.

You are preparing to palpate a patient's abdomen during a comprehensive assessment. You will likely use which part of your hand?

Palm Abdominal palpation is normally performed using the palm of the hand in order to accurately distinguish the characteristics of underlying structures. The back of the hand, the finger pads, and the ulnar surfaces are not adequate for this purpose.

For which assessment would the nurse plan to use direct percussion? Sinuses Kidneys Liver Gallbladder

Sinuses The nurse performs direct percussion by tapping the fingers directly on the client's skin, such as for assessment of the sinuses. The nurse performs indirect percussion by using the non-dominant hand as a barrier between the nurse's dominant hand and the client to assess organs, such as the gallbladder, kidneys, and liver.

It is recommended that a left-handed examiner adopt a right-sided position. True False

True

When is it necessary for a nurse to change gloves? Select all that apply. When touching a noncontaminated client more than once Between tasks and procedures on the same client Between taking the same client's blood pressure and temperature When going from a contaminated area to a cleaner area After contact with material that contains a high concentration of microorganisms

When going from a contaminated area to a cleaner area After contact with material that contains a high concentration of microorganisms The nurse changes gloves (1) between tasks and procedures on the same client after contact with material that contains a high concentration of microorganisms and (2) when going from a contaminated area to a cleaner area. Gloves are removed promptly after use, before touching noncontaminated items and environmental surfaces and before going to another client.

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

bone Flatness is a sound heard over very dense tissue like 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 .a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular c, d, e, b, a d, b, a, e, c a, c, b, d, e c, e, b, d, a d, e, b, a, c

c, d, e, b, a When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

You should use the bell of the stethoscope when auscultating what type of sounds? Abnormal sounds High-frequency sounds Low-frequency sounds Sounds that are partially audible without a stethoscope

Low-frequency sounds The bell is used with light skin contact to hear low-frequency sounds.

What steps should you take when documenting and assessing inspection findings?

Note normal and abnormal findings , Compare inspection findings with verbal and nonverbal cues , Use correct medical terminology to describe and document findings , Identify any patterns or clusters of findings When documenting and assessing inspection findings, note normal and abnormal findings, use correct medical terminology to describe and document findings, compare inspection findings with verbal and nonverbal cues, and identify any patterns or clusters of findings.

Your lab instructor explains that physical examination relies on what cardinal assessment technique? Assessment Percussion Organization Communication

Percussion Note that the physical examination relies on four classic techniques: inspection, palpation, percussion, and auscultation.

A young man has presented to the clinic with a two-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness?

Direct percussion is used to check the lungs of a newborn or check a patient's sinuses.

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? Resonant Tympanic Hyperresonant Flat

Hyperresonant 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.

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?

Vital signs The nurse should begin with a general survey, which includes taking the client's vital signs.

Light palpation is most appropriate to assess the appendix bladder inflamed areas of skin liver

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).

Indirect Percusssion

the most common type of percussion. You will use it to determine the size and density of organs and tissues in the lungs and abdomen. Steps include placing most of the middle finger of the non dominant hand on the body surface and striking this finger with the middle finger of your dominant hand while keeping all the other fingers off the body surface.

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? Cervical spine Thorax Axillary nodes Balance

Balance The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the client in the seated position. The thorax is assessed in either the sitting or lying position.

Which part of the hand is best for assessing temperature?

Dorsa/back of the hand The dorsa (back) of the hand can be used to gauge temperature more accurately than other surfaces 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? Inform the client that an assessment must be completed in order to provide treatment. Tell the client she may have a friend or family member stay with her during the assessment. Explain to the client why the assessment is important and the possibility of missing important findings. Respect the client's decision and do not press her on the issue.

Explain to the client why the assessment is important and the possibility of missing important findings. The nurse should respect the client's request but should also inform her of the risks of not performing the assessment. The nurse cannot force a client to allow the assessment or deny treatment if the assessment is not allowed. Telling the client that she can have someone with her during the procedure may or may not change the client's mind about the assessment.

You are assessing a 32-year-old woman with unexplained lesions on her back. You are going to palpate the area of the lesions. What type of palpation should you use?

Light Actually, light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin.

The ulnar edge of the hand is highly receptive to which of the following sensations? Moisture and contour Vibrations and moisture Contour and temperature Temperature and vibrations

Temperature and vibrations The dorsum and ulnar edge of the hands are both highly receptive to temperature variations as a result of their minimally keratinized skin surfaces. The ulnar edge also has the sensitivity to detect vibrations. It is less sensitive to moisture, vibrations, and contour.

The nurse would use what part of the hand when assessing temperature during palpation? Dorsal surface Finger pads Ulnar surface Palmar surface

Dorsal surface The dorsal surface is used for temperature. The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus

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 client. The nurse should be aware of what risk when using this assessment technique? Risk for injury Risk for infection Risk for chronic pain Risk for impaired skin integrity

Risk for injury With deep palpation, you might say, "I'm going to touch you and push down more deeply than before. Let me know if you feel pain or want me to stop." As palpation proceeds, continue conversation, asking the client about pain, presenting symptoms, or contributing factors while observing for nonverbal signs of tenderness or discomfort.

Which illustrates the nurse using the technique of inspection? The nurse detects a fruity odor of the client's breath. The nurse notes increased warmth surrounding the client's incision. The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse detects tympany over the client's lower abdomen.

The nurse detects a fruity odor of the client's breath. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the client's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

When should the nurse perform hand hygiene? Select all that apply. When hands are visibly soiled After removing gloves After providing mouth care After reconciling the client's medications After taking the blood pressure of a client with intact skin

When hands are visibly soiled After removing gloves After providing mouth care After taking the blood pressure of a client with intact skin Hand hygiene sometimes means hand washing with soap and water but at other times can involve only decontamination with an alcohol-based hand rub, depending on the circumstance. Hand hygiene is required when the nurse's hands are visibly soiled, after removing gloves, after providing mouth care, and after taking the blood pressure of a client with intact skin. Reconciling the client's medications means comparing the medications the client is prescribed and is actually using to new medications that are ordered to resolve any discrepancies; this activity does not require hand hygiene.

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? Snellen E chart Braden scale Penlight Reflex (percussion) hammer

Braden scale The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores. The Snellen E chart is used to test distant vision. The penlight is used to view the mouth and throat and to transilluminate the sinuses. The reflex (percussion) hammer is used to test tendon reflexes.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? Reflex hammer Tuning fork Tongue depressor Coin or key

Coin or key 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.

The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position? Range of motion of the spine Posterior chest excursion Head and neck range of motion Dorsiflexion of the foot

Dorsiflexion of the foot Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the client in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the client in the sitting position.

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? Light palpation Moderate palpation Deep palpation Bimanual palpation

Light palpation 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.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? Ophthalmoscope Tuning fork Otoscope Penlight

Ophthalmoscope An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses.

For which assessment would the nurse plan to use light palpation? Papular rash Shape of abdominal mass Size of liver Pulsation of abdominal aorta

Papular rash Light palpation is used to assess surface characteristics, such as a papular rash. Deep palpation is used to assess the size, shape, and consistency of abdominal organs.

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

palpation Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? pad the table use as a drape collect body fluids serve as a head support

use as a drape During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.

How should the nurse place the ear of an adult when using the otoscope? Up and back Down and back Up and forward Down and forward

Up and back When using the otoscope on an adult, the ear should positioned up and back.

physical assessment order

The IPPA format typically follows a sequence of inspection, palpation, percussion, and auscultation.

A nurse is preparing to conduct an assessment on a client. In what order should the nurse conduct the following actions?

Wash hands and don gloves. Take the client's vital signs. Assess eyes, ears, nose, and mouth. Auscultate heart and lung sounds. Assess genitalia. In order to decrease anxiety and build rapport, the nurse should explain to the client what they are doing and why. Less intrusive procedures should be performed first, for example, vital signs; height and weight; and inspection of hair, eyes, ears, mouth, skin, posture, and so on. Assessments should be conducted in an orderly fashion, generally starting at the head and moving downward, leaving the most invasive for last, such as examining genitalia. To reduce the transmission of microorganisms, the nurse must wash hands and don gloves prior to assessing a client.

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area? percussion auscultation light palpation deep palpation

auscultation During the abdominal examination, the pattern will be inspection, auscultation, percussion, and palpation. Auscultation follows inspection so as not to increase bowel motility with palpation.

The nursing instructor is teaching nursing students about hand hygiene prior to performing a health assessment. The nursing instructor determines effectiveness of the teaching when the students state that hand hygiene should occur at which point? Select all that apply. before touching a client before eating before leaving a client's room when hands become visibly soiled immediately before glove removal

before touching a client before eating before leaving a client's room when hands become visibly soiled Hand hygiene should occur immediately before touching a client, before and after eating, before leaving a client's room, immediately after (not before) glove removal, and when hands are soiled. Hands must be washed with soap and water when they become visibly soiled.

A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? Parasites Blood Bacteria Fungus

Blood After an anal exam, fecal material is tested for the presence of blood. Testing for other organisms requires specialized specimen collection.

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 Disinfect the stethoscope after touching the client Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface Put on a personal protection gown

Disinfect the stethoscope before touching the client The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens. Disinfecting the stethoscope after touching the client does not answer the question being asked. Placing the stethoscope directly on the client's skin does not answer the question being asked. Nothing noted in the question would require the nurse to wear a personal protection gown.

The most commonly used type of percussion is:

Indirect Percussion Indirect percussion is used to assess the size and density of the organs in the chest and abdomen. It is used more commonly than direct percussion or blunt percussion. There is no such thing as deep percussion.

The nurse wears gloves for which of the following purposes? Select all that apply. Prevent transmission of flora from client to client. Increase the risk of the nurse acquiring infection from the client. Limit exposure to body fluids and secretions Facilitate contamination of the hands of the nurse.

Limit exposure to body fluids and secretions Prevent transmission of flora from client to client. The nurse wears gloves to prevent transmission of flora from client to client, prevent exposure to body fluids and secretions, decrease the risk of the nurse acquiring infection from the client, and reduce contamination of the hands of the nurse.

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. Begin at the head and move in a systematic approach. Auscultate all necessary body systems to prevent disturbing any organs. Allow the client to undress and put on a gown.

Measure the client's vital signs, height, and weight. It is important to begin the assessment with less intrusive procedures such as vital signs and height and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed.

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 Ophthalmoscope Opaque card Penlight

Snellen chart 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.

Which describes the nurse using the technique of auscultation? The nurse detects gurgling throughout the abdomen. The nurse detects foul odor of the urine. The nurse notes a small nodule in the breast. The nurse notes dullness over the liver.

The nurse detects gurgling throughout the abdomen. Auscultation is used by the nurse to assess bowel sounds, such as gurgling throughout the abdomen. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors, such as foul smelling urine. The nurse uses palpation to detect nodules in the breast by the use of touch. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as dullness over the liver.

The nurse is caring for the client who is receiving heparin. The nurse plans to: Wear clean gloves when administering heparin to the client Recap the needle after administering heparin to the client Perform hand hygiene with alcohol-based gel after administering the heparin Wear a mask when administering heparin to the client

Wear clean gloves when administering heparin to the client Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.

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? Wood's light Penlight Magnifying glass Examination light

Wood's light Wood's light is a special piece of examination equipment that is used to test for fungus. A penlight is used for more general assessments, such as of the mouth and throat and to transilluminate the sinuses. A magnifying glass is used to enlarge the visibility of a lesion. An examination light is used to better illuminate the client's body as a whole to facilitate physical examination.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using inspection. palpation. Doppler magnification. percussion.

percussion. Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.

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 anklesb. Groin, hips, and kneesc. Breastsd. Chest and thoraxe. Cardiovascular c, d, e, b, a d, b, a, e, c a, c, b, d, e c, e, b, d, a d, e, b, a, c

c, d, e, b, a When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

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. Glasses Ophthalmoscope Goniometer Stethoscope Skin-fold calipers

Ophthalmoscope Goniometer Skin-fold calipers Some physical assessment techniques require special equipment. Examples of special tools include an ophthalmoscope, visual acuity chart, otoscope, tuning fork, percussion hammer, vaginal speculum, goniometer, and skin-fold calipers. Glasses and a stethoscope are not considered specialized tools.

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 ear wax 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? Stethoscope Otoscope Ophthalmoscope Sphygmomanometer

Otoscope An otoscope is a device used to view the ear canal and tympanic membrane. A stethoscope is used to auscultate breath and heart sounds in the chest. An ophthalmoscope is used to view the red reflex of the eye and to examine the retina of the eye. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.

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? Fingertips Palmar surface Dorsal surface Finger pads

Palmar surface The ulnar-or palmar-surface is the part of the hand used to palpate vibrations. The fingertips are not used to palpate. The dorsal surface is sensitive to temperature and the finger pads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitus.

Prior to beginning the physical examination, the nurse should perform which actions to ensure the examination flows smoothly? Select all that apply. Check the batteries in the penlight. Check to ensure the otoscope is functioning. Clean the stethoscope. Memorize the mini mental status examination. Ask the client to drape himself or herself.

Check the batteries in the penlight. Check to ensure the otoscope is functioning. Clean the stethoscope. In order to ensure the physical examination flows smoothly, the nurse should check all required equipment is functioning before beginning the examination. The stethoscope should be sanitized with an antibacterial solution such as rubbing alcohol in between the assessment of clients and prior to beginning the examination. It is not necessary to memorize the mini mental status examination. This tool needs to be brought into the examination because the client is an active participant (the client has to look at the examination and draw on the sheet). The client will not have the clinical skill to be able to drape himself or herself for the examination to flow smoothly; the nurse is responsible for completing this task.

You are performing a physical examination on a new client. What would you be assessing if you were testing the client's sense of smell? Cranial nerves Nose Upper neuron function Strength of nerve functioning

Cranial nerves If not already examined, check sense of smell, strength of the temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength of the trapezia and sternomastoid muscles.

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. Eliminate distracting noises from the environment Place the diaphragm against the client's clothing Readjust the ear pieces to ensure a snug fit Angle the binaurals towards the nose Tell the client to hold their breathe

Eliminate distracting noises from the environment Readjust the ear pieces to ensure a snug fit Angle the binaurals towards the nose To enhance the sounds from the stethoscope, the nurse should eliminate distracting or competing sound from the environment. The ear piece should fit comfortably but snugly in to the ear canals with the binaurals towards the nose to ensure the sounds are transmitted to the ear drums. The stethoscope should be places against the client's skin to prevent rubbing of the clothing. The client should not be instructed to hold the breath because this could alter the hear sounds.

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. You are implementing actions to help reduce the client's anxiety during the physical exam. Which of the following would be most appropriate?

Ensuring client's privacy by providing an examination gown

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? Application of firm pressure when using the bell Using the diaphragm to listen to low-pitched sounds Using the bell to detect high-pitched sounds Ensuring that contact with the skin is maintained

Ensuring that contact with the skin is maintained While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.

Equipment used in conducting a physical examination includes a gauze pad. What is this used for? Testing facial sensation Invoking the blink reflex Inverting the eyelid Examining the tongue

Examining the tongue Gauze pads are used during tongue examination. An applicator or tongue blade might be used to help invert the eyelid.

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? Comply with the client's request and proceed with the rest of the examination Insist that the client undress and allow her breasts to be examined, for her own good Ask the physician to perform the examination Explain the importance of the examination and the risks of breast cancer

Explain the importance of the examination and the risks of breast cancer If a client requests that a certain part of the examination, such as the breast examination, not be performed, the nurse should explain the importance of the examination and the risk of missing important information if any part is omitted. Simply complying with the client's request, insisting on the examination, and asking the physician to perform it would not be appropriate actions.

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 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.

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? Reflex hammer Skinfold calipers Flexible metric measuring tape Goniometer

Goniometer A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee. Skinfold calipers are used to measure skinfold thickness of subcutaneous tissue. A flexible metric measuring tape may be used for many purposes, including measuring the size of extremities.

Which of the following statements is true of the role of inspection in the physical examination? It should be performed after auscultation but before palpation and percussion. It is often the source of the most physical signs. To maximize findings, local inspection should be conducted prior to general inspection. The acuity of the client will determine whether general or local inspection should be implemented in the examination.

It is often the source of the most physical signs. Inspection often yields the most signs during an examination. It should begin the examination, and general inspection precedes local inspection. The two are not mutually exclusive and should both be implemented in each examination.

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 Prone Supine Dorsal recumbent

Knee-chest The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. 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. 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 dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.

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? Supine Lithotomy Standing Prone

Lithotomy 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.

As the density of tissue decreases, the percussion note becomes: Softer Shorter Lower pitched Less musical

Lower pitched Low density tissue tends to produce sound that is lower pitched, musical, loud, and longer in duration than in denser tissue.

The nurse is performing percussion over the lung fields. The nurse hears a dull tone in the lower lung fields, which is a new finding. What is the next best action of the nurse? Notify the health care provider and prepare to transport the client for a chest x-ray. Document findings and reassess in 4 hours. Reposition the client in side-lying position and apply oxygen. Alert the critical assessment team.

Notify the health care provider and prepare to transport the client for a chest x-ray. This is an abnormal finding because resonance should be heard over the lung fields, which are part air and part solid (that is, the lung intensity is loud, pitch is low, length is long, and quality is hollow). Dullness is heard over more solid tissue, such as an organs or solid soft mass or effusions. Therefore, the nurse should notify the health care provider of this new finding and prepare to transport the client for a chest x-ray for further analysis of the findings. Although the nurse will document findings, they should not wait 4 hours to reassess the client. The nurse should position the client in Fowler, high Fowlers, or tripod position to improve lung expansion and oxygenation, not a side-lying position. There is no indication that the client requires oxygen at this time. There is no indication that the critical assessment team needs to be alerted.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? Percuss the region before auscultating. Palpate the region before auscultating. Assist the client to a sitting position. Reduce all environmental noise.

Reduce all environmental noise. Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the client to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the client in the lying position.

4The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following?

Resonance A loud, low-pitched, hollow sound is called 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? Platform scale with height attachment Metric ruler Sphygmomanometer Skinfold calipers

Skinfold calipers 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.

What is used to gauge central and peripheral nervous system disorders? Strength of a reflex Gait Tuning fork Heat and cold

Strength of a reflex The strength of a reflex is used to gauge central and peripheral nervous system disorders.

You perform percussion during an assessment, and the procedure causes the patient pain. What is the most likely indication of this finding?

There is inflammation in an underlying structure. Pain during percussion is not expected and has varied causes. However, inflammation of an underlying structure is among the most likely causes. This may or may not be related to a systemic illness or malignancy.

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation? Intestines Muscles Thyroid gland Pancreas

Thyroid gland Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? After the physical examination is completed When the demographic data has been documented Upon meeting the client and family members As soon as any visitors have left the room

Upon meeting the client and family members The general survey begins immediately when meeting the client and continues throughout the assessment.

A nurse is preparing to conduct an assessment on a client. In what order should the nurse conduct the following actions? Place the steps in the correct order. Assess eyes, ears, nose, and mouth. Take the client's vital signs. Auscultate heart and lung sounds. Assess genitalia. Wash hands and don gloves.

Wash hands and don gloves. Take the client's vital signs. Assess eyes, ears, nose, and mouth. Auscultate heart and lung sounds. Assess genitalia. In order to decrease anxiety and build rapport, the nurse should explain to the client what they are doing and why. Less intrusive procedures should be performed first, for example, vital signs; height and weight; and inspection of hair, eyes, ears, mouth, skin, posture, and so on. Assessments should be conducted in an orderly fashion, generally starting at the head and moving downward, leaving the most invasive for last, such as examining genitalia. To reduce the transmission of microorganisms, the nurse must wash hands and don gloves prior to assessing a client.

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen? light palpation moderate palpation direct palpation deep palpation

deep palpation Deep or bimanual palpation is contraindicated in clients presenting with signs and symptoms of appendicitis, enlarged spleen, or abdominal aortic aneurysm (AAA). Deep palpation may cause rupture of the organ or artery. Moderate palpation should be performed; the client will most likely present with rebound tenderness. Light palpation may be performed to assess rigidity and warmth. Direct percussion is performed to produce sound or elicit pain to assess underlying structures, for example, sinuses and the thorax.

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 light palpation. moderate palpation. deep palpation. very deep palpation.

very deep palpation. 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.