Health Assessment Exam 2

Which of the following techniques are used in a physical assessment? Select all that apply. 1. Palpation 2. Inspection 3. Subjectivity 4. Questioning 5. Auscultation

1, Palpation. 2, Inspection. 5, Auscultation.

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client? 1. "They make sure that any microorganisms on my hands do not touch your skin." 2. "Since we don't know what's wrong with you, I wear gloves to make sure I don't get sick." 3. "They help me feel your body parts under your skin better." 4. "It's a policy I have to follow."

1. "They make sure that any microorganisms on my hands do not touch your skin."

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform? 1. Application of an alcohol-based hand rub 2. Nonantimicrobial soap and water with friction 3. No washing is needed because hands are not soiled. 4. Hand wash with antiseptic soap

1. Application of an alcohol-based hand rub

Universal precautions are primarily designed to protect the health care worker from what? 1. Blood-borne pathogens 2. Respiratory diseases 3. Musculoskeletal injuries 4. STDs

1. Blood-borne pathogens

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. 1. Eliminate distracting noises from the environment 2. Tell the client to hold their breathe 3. Readjust the ear pieces to ensure a snug fit 4. Place the diaphragm against the client's clothing 5. Angle the binaurals towards the nose

1. Eliminate distracting noises from the environment, 3. Readjust the ear pieces to ensure a snug fit, 5. Angle the binurals towards the nose

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. 1. Gown 2. Gloves 3. Face shield 4. Stethoscope 5. Nasopharyngeal airway

1. Gown, 2. Gloves, 3. Face shield

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? 1. Inspection, palpation, percussion, auscultation 2. Percussion, palpation, inspection, auscultation 3. Auscultation, percussion, palpation, inspection 4. Palpation, inspection, auscultation, percussion

1. Inspection, palpation, percussion, auscultation

Which illustrates the nurse using the technique of inspection? 1. The nurse detects a fruity odor of the client's breath. 2. The nurse notes a rhythmic lub-dub over the client's anterior thorax. 3. The nurse detects tympany over the client's lower abdomen. 4. The nurse notes increased warmth surrounding the client's incision.

1. The nurse detects a fruity odor of the client's breath.

Which describes the nurse using the technique of percussion? 1. The nurse notes resonance over the individual's thorax. 2. The nurse detects rustling over the individual's thorax. 3. The nurse notes symmetry of the individual's thorax. 4. The nurse detects crepitus over the individual's thorax.

1. The nurse notes resonance over the individual's thorax

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? 1. Upon meeting the client and family members 2. After the physical examination is completed 3. As soon as any visitors have left the room 4. When the demographic data has been documented

1. Upon meeting the client and family members

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) 1. Wash hands. 2. Dim the lighting to promote comfort 3. Turn on relaxing music of the client's choice 4. Identify ways to ensure client privacy. 5. Obtain and check needed equipment.

1. Wash hands 2. Identify ways to ensure client privacy 5. Obtain and check needed equipment

You should use the bell of the stethoscope when auscultating what type of sounds? 1. Abnormal sounds 2. Low-frequency sounds 3. High-frequency sounds 4. Sounds that are partially audible without a stethoscope

1. abnormal sounds

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 1. blunt percussion. 2. moderate palpation. 3. indirect percussion. 4. deep palpation.

1. blunt percussion

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's 1. bone. 2. abdomen. 3. liver. 4. lungs.

1. bone

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? 1. Dorsiflexion of the foot 2. Head and neck range of motion 3. Posterior chest excursion 4. Range of motion of the spine

1. dorsiflexion of the foot

Light palpation is most appropriate to assess the 1. inflamed areas of skin 2. appendix 3. liver 4. bladder

1. inflamed areas of skin

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? 1. Warm, comfortable room 2. Adequate lighting 3. Firm examination bed or table 4. Quiet area free of disturbance

2. Adequate lighting

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? 1. Percussion 2. Palpation 3. Inspection 4. Auscultation

2. Palpation

For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.) 1. Texture of a mole 2. Pulsation of abdominal aorta 3. Shape of abdominal mass 4. Macular rash 5. Size of liver

2. Pulsation of abdominal aorta 3. Shape of abdominal mass 5. Size of liver

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? 1. Percuss the region before auscultating. 2. Reduce all environmental noise. 3. Palpate the region before auscultating. 4. Assist the client to a sitting position.

2. Reduce all environmental noise.

What would be the expected tone elicited by percussion of a normal lung? 1. Tympany 2. Resonance 3. Hyper-resonance 4. Dullness

2. 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? 1. Platform scale with height attachment 2. Skinfold calipers 3. Metric ruler 4. Sphygmomanometer

2. Skinfold calipers

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 1. light palpation. 2. deep palpation. 3. very deep palpation. 4. moderate palpation.

2. deep palpation

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? 1. Elasticity 2. Texture 3. Color 4. Temperature

3. Color

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for? 1. Testing facial sensation 2. Invoking the blink reflex 3. Examining the tongue 4. Inverting the eyelid

3. Examining the tongue

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness? 1. Hand-washing throughout the exam 2. Draping body areas that are not being assessed. 3. Limit position changes as much as possible 4. Using alcohol swabs to clean the stethoscope

3. Limit position changes as much as possible

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? 1. Penlight 2. Ophthalmoscope 3. Snellen chart 4. Opaque card

3. Snellen chart

Which action by a nurse demonstrates the correct application of the principles of standard precautions? 1. Using an antiseptic hand scrub to cleanse visibly soiled hands. 2. Change gloves after each body area is examined 3. Wearing gloves when palpating the tongue, lips, & gums 4. Wearing a gown, gloves, and mask for the physical exam

3. Wearing gloves when palpating the tongue, lips, & gums

While examining a client, the nurse plans to palpate temperature of the skin by using the 1. ulnar surface of the hand. 2. fingertips of the hand. 3. palmar surface of the hand. 4. dorsal surface of the hand.

3. dorsal surface of the hand

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? 1. Flat 2. Resonant 3. Hyperresonant 4. Tympanic

3. hyperresonant

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? 1. stethoscope 2. sphygmomanometer 3. otoscope 4. ophthalmoscope

3. otoscope

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? 1. Reflex (percussion) hammer 2. Snellen E chart 3. Penlight 4. Braden scale

4. Braden Scale

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? 1. Put on a personal protection gown 2. Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface 3. Disinfect the stethoscope after touching the client 4. Disinfect the stethoscope before touching the client

4. Disinfect the stethoscope before touching the client

When assessing pulses, the nurse would use which part of the hand for palpation? 1. Palmar surface 2. Ulnar surface 3. Dorsal surface 4. Finger pads

4. Finger pads

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? 1. Moderate palpation 2. Deep palpation 3. Bimanual palpation 4. Light palpation

4. Light palpation

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? 1. Supine 2. Standing 3. Prone 4. Lithotomy

4. Lithotomy

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? 1. Begin at the head and move in a systematic approach. 2. Auscultate all necessary body systems to prevent disturbing any organs. 3. Allow the client to undress and put on a gown. 4. Measure the client's vital signs, height, and weight.

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

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? 1. Tympany 2. Hyper-resonance 3. Dullness 4. Resonance

4. Resonance

Which describes the nurse using the technique of auscultation? 1. The nurse notes a small nodule in the breast. 2. The nurse detects foul odor of the urine. 3. The nurse notes dullness over the liver. 4. The nurse detects gurgling throughout the abdomen.

4. The nurse detects gurgling throughout the abdomen

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? 1. Penlight 2. Magnifying glass 3. Examination light 4. Wood's light

4. Wood's light

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? 1. Breath 2. Bowel 3. Normal heart 4. Heart murmur

4. heart murmur

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? 1. collect body fluids 2. pad the table 3. serve as a head support 4. use as a drape

4. use as a drape

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 (breasts), d (chest and thorax), (cardiovascular) e, b (groin, hips, and knees), a (shins and ankles)