Health Assessment Prep U Chapter 3

Light palpation is most appropriate to assess the

inflamed areas of skin.

The nurse is conducting a physical examination of a client who is lying down. What is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

Which of the following is a general procedural rule when performing a complete physical examination?

Examine the right then the left side of the body.

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

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 sounds?

Heart murmur

What is the relevance of the role of inspection in the physical examination?

It is often the course of the most physical signs.

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

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

Lungs

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

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

Ophthalmoscope

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

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?

Application of an alcohol based hand rub

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 all environmental noise.

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. What describes this finding?

Resonance

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

Gloves, mask, protective eye goggles, gown

After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do?

Go back in to complete a physical examination of the skin.

What are some of the techniques used in a physical assessment?

Inspection Palpation Auscultation

A nurse is preparing to perform a genital examination of a female client. Which of the following position should the nurse place the client in?

Lithotomy

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?

Palpation

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

Resonance

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

A nurse is preparing to perform a physical examination of an obese client who is beginning to 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

During palpation of a client's organs, the nurse palpates the spleen by Appling pressure between 2.5 and 5 centimeters. The nurse is performing

deep palpation.

What describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

Up and back

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at what point in the admission process?

Upon meeting the client and family members

What is an action by a nurse that demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, and gums

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

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

bone.

While examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand.

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.

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?

otoscope

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

Equipment use in conducting a physical examination includes a 2x2 gauze pad. What is this used for?

Examining the tongue

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

Light palpation

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

During a comprehensive assessment, the primary technique used but the nurse throughout the examination is

inspection.

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

Balance

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

Decreased breath sounds unilaterally

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

Palpation

The nurse wears gloves for what purposes?

Limit exposure to body fluids and secretions. Prevent transmission of flora from client to client.

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

What illustrates the nurse using the technique of inspection?

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

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

Indirect Percussion

The nurse is conducting a physical examination of a client who is in the lying position. In what order would the nurse assess the patient when completing the examination?

Breasts Chest and Thorax Cardiovascular Groin, Hips, and Knees Shins and Ankles

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

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?

Ensuring that contact with the skin is maintained

A nurse must examine the rectum of a woman who has complained of feeling from the anus and pain on defecating. What position would be most appropriate for the client?

Knee-chest (Sims)

The nurse is assessing a client with unexplainable 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

T/F: It is recommended that a left-handed examiner adopt a right-sided position.

True

A nurse in the community is completing a manual blood pressure assessment. What action should the nurse take to ensure the assessment is accurate?

Turn down the television volume.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

The nurse is preparing the examination room before assessing a client. What is the purpose of a clean folded sheet on the examination table?

Use as a drape