Jarvis Chapter 8: Assessment Techniques and Safety in the Clinical Setting

When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen

Abdomen

During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How should the nurse interpret this type of sound? a. Constipation b. Air-filled areas c. Presence of a tumor d. Presence of dense organs

Air-filled areas

A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment? a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the child's clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Allow the child to keep a security object such as a toy or blanket during the examination.

An adult male is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

Appear unhurried and confident when examining him.

When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes as possible.

Arrange the sequence of the examination to allow as few position changes as possible.

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action should the nurse take? a. Ask the patient how he or she is feeling. b. Document the findings in the patient's record. c. Wait 10 minutes, and auscultate the sound again. d. Ask another nurse to double check the finding.

Ask another nurse to double check the finding.

The nurse is preparing to examine an infant. At what point in the examination should the nurse attempt to elicit the Moro reflex? a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. At about the middle of the examination

At the end of the examination

A 6-month-old infant has been brought to the well-child clinic for a checkup. She is currently sleeping. What should the nurse do first when beginning the examination? a. Wake the infant before beginning the examination. b. Examine the infant's hips before the infant wakes up. c. Auscultate the lungs and heart while the infant is still sleeping. d. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.

Auscultate the lungs and heart while the infant is still sleeping.

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b. Obtain a thorough history and physical assessment from the patient's family member. c. Immediately perform a complete history and physical assessment to obtain baseline information. d. Examine the body areas appropriate to the problem and perform the rest of the complete assessment after the problem has resolved

Examine the body areas appropriate to the problem and perform the rest of the complete assessment after the problem has resolved

The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group? a. Explain the procedures in detail to alleviate the child's anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen.

Give the child feedback and reassurance during the examination.

When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Washing one's hands after removing gloves is not necessary, as long as the gloves are still intact. b. Hands are washed before and after every physical patient encounter. c. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

Hands are washed before and after every physical patient encounter.

Which should the nurse do when preparing to perform a physical examination on an infant? a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during abdominal auscultation. d. Ask the parent to leave the room briefly when assessing the infant's vital signs.

Have the parent remove all clothing except the diaper on a boy.

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? (Select all that apply.) a. Identify any tender areas and palpate them last. b. Warm the hands first before touching the patient. c. Use the palms of the hands to assess temperature of the skin. d. Start with light palpation to detect surface characteristics. e. For deep palpation, use one long continuous palpation when assessing the liver. f. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.

Identify any tender areas and palpate them last. Warm the hands first before touching the patient. Start with light palpation to detect surface characteristics. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.

The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen.

Increase the amount of strength used when attempting to percuss over the abdomen.

When performing a physical assessment, what technique should the nurse always perform first? a. Palpation b. Inspection c. Percussion d. Auscultation

Inspection

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope of the earpieces should point posteriorly (toward the occiput). b. It blocks out extraneous room noise but does not magnify sound. c. The tubing length should be 22 inches to dampen the distortion of sound. d. Fit and quality of the stethoscope are not as important as its ability to magnify sound.

It blocks out extraneous room noise but does not magnify sound.

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? a. Performs the examination from the left side of the bed b. Examines tender or painful areas first to help relieve the patient's anxiety c. Follows the same examination sequence, regardless of the patient's age or condition d. Organizes the assessment to ensure that the patient does not change positions too often

Organizes the assessment to ensure that the patient does not change positions too often

The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations d. Assessing the presence of tenderness and pain

Palpating the kidneys and uterus

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation

Palpation

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation

Palpation

The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene? a. Percussing once over each area b. Striking with the fingertip, not the finger pad c. Using the wrist to make the strikes, not the arm d. Quickly lifting the striking finger after each stroke

Percussing once over each area

What action by the nurse is appropriate when examining a 16-year-old male teenager? a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him in the same manner as one would talk to a younger child because a teen's level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.

Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.

An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed? a. Rotating the lens selector dial to bring the object into focus b. Using the large full circle of light when assessing pupils that are not dilated c. Rotating the lens selector dial to the black numbers to compensate for astigmatism d. Using the grid on the lens aperture dial to visualize the external structures of the eye

Rotating the lens selector dial to bring the object into focus

Which of these statements is true regarding the use of Standard Precautions in the health care setting? a. Standard Precautions apply to all body fluids, including sweat. b. Alcohol-based hand rub should be used if hands are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.

The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment? a. Usually yields little information b. Takes time and reveals a surprising amount of information c. May be somewhat uncomfortable for the expert practitioner d. Requires a quick glance at the patient's body systems before proceeding with palpation

Takes time and reveals a surprising amount of information

The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The child is asked to undress from the waist up. b. The thorax, abdomen, and genitalia are examined before the head. c. The nurse should keep in mind that a child at this age will have a sense of modesty. d. Talking about the equipment being used is avoided because doing so may increase the child's anxiety

The nurse should keep in mind that a child at this age will have a sense of modesty.

While performing the physical examination, the nurse shares information and briefly teaches the patient. Why does the nurse do this? a. To help the examiner feel more comfortable and gain control of the situation b. To build rapport and increase the patient's confidence in the examiner c. To assist the patient in understanding his or her disease process and treatment modalities d. To aid the patient to identify questions about his or her disease and the potential areas of needed education

To build rapport and increase the patient's confidence in the examiner

The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next? a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope.

Use a Doppler device to check for pulsations over the area.

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? a. Used to listen for high-pitched sounds b. Used to listen for low-pitched sounds c. Should be lightly held against the person's skin to block out low-pitched sounds d. Should be lightly held against the person's skin to listen for extra heart sounds and murmurs

Used to listen for high-pitched sounds

What is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting? a. Wear protective eye wear at all times. b. Wear gloves whenever in direct contact with patients. c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients.

Wash hands before and after contact with each patient.

The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Wash hands and then contact the physician. b. Continue to examine the ulceration and then wash hands. c. Wash hands, put on gloves, and continue with the examination of the ulceration. d. Wash hands, proceed with rest of the physical examination, and perform the examination of the leg ulceration last.

Wash hands, put on gloves, and continue with the examination of the ulceration.

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. "Your atrial dysrhythmias are under control." b. "You have pitting edema and mild varicosities." c. "Your pulse is 80 beats per minute, which is within the normal range." d. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."

"Your pulse is 80 beats per minute, which is within the normal range."

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a. Avoid palpation of reportedly "tender" areas because palpation in these areas may cause pain. b. Palpate a tender area quickly to avoid any discomfort that the patient may experience. c. Start the assessment with deep palpation, while encouraging the patient to relax and take deep breaths. d. Begin the assessment with light palpation to detect surface characteristics and to accustom the patient to being touched.

Begin the assessment with light palpation to detect surface characteristics and to accustom the patient to being touched.

While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse's palm of the hand

Bell of the stethoscope

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Count the patient's respirations. b. Bilaterally percuss the thorax, noting any differences in percussion tones. c. Call for a chest x-ray, and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations

Bilaterally percuss the thorax, noting any differences in percussion tones.

The nurse is preparing to auscultate the abdomen. How should the nurse proceed? a. Warm the endpiece of the stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure that the bell side of the stethoscope is turned to the "on" position. d. Check the temperature of the room and offer blankets to the patient if he or she feels cold.

Check the temperature of the room and offer blankets to the patient if he or she feels cold.

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate? a. Asking questions enhances the child's autonomy. b. Asking the child for permission helps develop a sense of trust. c. This question is an appropriate statement because children at this age like to have choices. d. Children at this age like to say, "No." The examiner should not offer a choice when no choice is available.

Children at this age like to say, "No." The examiner should not offer a choice when no choice is available.

While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do? a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands, and attempt to percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment

Consider this a normal finding.

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. How should the nurse proceed? a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths, and percuss over the area again. c. Refer the child to a specialist because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination

Consider this finding as normal for a child this age, and proceed with the examination

The nurse is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess? a. Turgor b. Texture c. Density d. Consistency

Density

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? a. Often used to direct light onto the sinuses b. Used to examine the structures of the internal ear c. Uses a short, broad speculum to help visualize the ear d. Directs light into the ear canal and onto the tympanic membrane

Directs light into the ear canal and onto the tympanic membrane

The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature? a. Fingertips b. Dorsal surface of the hand c. Ulnar portion of the hand d. Palmar surface of the hand

Dorsal surface of the hand