Health Assessment Chapter 3 Questions

Which of the following techniques are used in a physical assessment? Select all that apply.

- Auscultation - Inspection - Palpation

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Balance

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

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

Dorsal surface

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

Low-frequency sounds

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

When entering a client's room, what is the nurse's first action?

Ask the client's name and birthdate.

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

When assessing pulses, the nurse would use which part of the hand for palpation?

Fingerpads

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.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath. Explanation: Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors.

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums

Light palpation is most appropriate to assess the

inflamed areas of skin

A client who reports having a burning rash in the perianal area says, "Just stop asking questions and look at the rash right now." Which response by the nurse is best?

"I just need to gather more information about your symptoms to help you the best way I can."

What included in personal protective equipment? Select all that apply.

- Gloves - Gown - Mouth, nose, eye protection

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

- Obtain and check needed equipment. - Identify ways to ensure patient privacy. - Wash hands.

For which patient should the nurse wear gloves to provide care? Select all that apply.

- The patient with Clostridium difficile - The patient with vancomycin-resistant enterococci - The patient requiring oropharyngeal suctioning

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 Explanation: Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours.

A nurse, who suffers from a respiratory infection, is preparing to perform a shift assessment on a client when she feels the urge to cough. What is the nurse's best action?

Cough into the inner aspect of the elbow.

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally Explanation: When a central line is placed, it can lead to a pneumothorax. A sign of a pneumothorax is decreased breath sounds on the affected side. The respiratory rate and temperature readings are expected. Elevated blood pressure is not a complication directly related to central line placement.

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 Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs.

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

Resonance

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

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. Explanation: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the patient's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

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