NUR230 chapter 3 PREPU

factors that cause temp variations

-diurnal cycle (sleep cycle) -menstruation -exercise -age -stress -exposure to cold or heat -illness

stage 1 hypertension

140-159 systolic 90-99 diastolic

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 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

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

The nurse is performing a physical assessment. The nurse does what first?

Inspection

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

Inspection Palpation Auscultation

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

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

Light palpation

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

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

Wearing gloves when palpating the tongue, lips, & gums

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

bone.

oral/axillary

oral-96.6-99.5 axillary-95.698.5

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

Sinus Arrhythmia

rhythm speeds up ( inspiration), slows down with breathing (expiration)

normal bpm

60-100

normal temp range

96-99.5

temporal

97.4-100.3

tympanic thermometer

98-100.9 useful with uncooperative patients , peds

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

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

Gloves Gown Mouth, nose, eye protection

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?

Goniometer

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

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

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

deep palpation.

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

dorsal surface of the hand.

stage 2 hypertension

greater than 160 systolic greater than 100 diastolic

Stage 3 hypertension

greater than 180/110

Light palpation is most appropriate to assess the

inflamed areas of skin

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

inspection.

pulse pressure

systolic-diastolic

general survey

the study of the whole person -starts the moment you meet the patient, gives overall impression to patient , observation skills while interacting with patient

To adhere to standard precautions, the nurse should remember to (Select all that apply.)

wash hands before and after patient contact change white coat frequently