Prep U chapter 3

balance

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

lower the bed height

The nurse has completed the physical examination of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the most important thing the nurse should do prior to leaving the room?

light

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?

Wear clean gloves when administering heparin to the client

The nurse is caring for the client who is receiving heparin. The nurse plans to:

Complete the forgotten portion of the exam out of sequence

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Reduce all environmental noise.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

hand hygiene

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

deep palpitation

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?

auscultation of the heart with the stethoscope bell

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

palpation

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

Asculatation

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?

snellen chart

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?

adequate lighting

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?

Right calf appears red. Right calf is warm to touch. Client grimaces when dorsiflexing the right calf.

A nurse conducts a focused assessment on a hospitalized client. Which objective finding(s) should the nurse document in the client's chart? Select all that apply.

Turn down the volume if the television or radio is on

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

Inspection, palpation, percussion, auscultation

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?

Ensuring that contact with the skin is maintained

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?

dorsal surface

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

resonance

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?

Explain the importance of the examination and the risks of breast cancer

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?

Lithotomy

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?

Eliminate distracting noises from the environment.

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Gloves Gown Face shield

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.

light palpitation

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

Disinfect the stethoscope before touching the client

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

heart murmur

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?

Practice performing a physical examination on a classmate, friend, or relative.

A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?

consult with a clinical instructor

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Go back in to complete a physical examination of the skin

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?

1½-inch diaphragm.

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

palpation

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?

lungs

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

papular rash

For which assessment would the nurse plan to use light palpation?

hearing loss

The nurse would use the tuning fork to assess for what?

dorsal surface

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

Borders of the heart

What can the nurse assess using percussion?

resonance

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

finger pads

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

Wearing gloves when palpating the tongue, lips, & gums

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

The nurse detects gurgling throughout the abdomen

Which describes the nurse using the technique of auscultation?

The nurse notes resonance over the individual's thorax.

Which describes the nurse using the technique of percussion?

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

Which illustrates the nurse using the technique of inspection?

Limit position changes as much as possible

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

To determine whether a structure is filled with air or fluid or is a solid structure

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?

low frequency sounds

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