TTT Exam 1 Chapter 3: Collecting Objective Data: The Physical Examination - ML8

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

Alcohol-based rub

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

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

Coin or key

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?

Complete the forgotten portion of the exam out of sequence.

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

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

Finger pads

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

Hand hygiene

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

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

Ophthalmoscope

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

Palmar surface

What auscultation sound would the nurse expect when listening to heart sounds?

Rhythmic lub-dub

For which assessment would the nurse plan to use direct percussion?

Sinuses

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland

It is recommended that a left-handed examiner adopt a right-sided position.

True

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

Up and back

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

Wearing gloves when palpating the tongue, lips, & gums

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?

auscultation of the heart with the stethoscope bell

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.

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?

inspection

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

percussion

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

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs.

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

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

Low-frequency sounds

The nurse is performing percussion over the lung fields. The nurse hears a dull tone in the lower lung fields, which is a new finding. What is the next best action of the nurse?

Notify the health care provider and prepare to transport the client for a chest x-ray.

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

Papular rash

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, 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

Which illustrates the nurse using the technique of inspection?

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

Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques?

Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques?

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

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?

deep palpation

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

inspection

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

Dorsal surface

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?

Dorsiflexion of the foot

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.

Eliminate distracting noises from the environment Readjust the ear pieces to ensure a snug fit Angle the binaurals towards the nose

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?

Eliminate distracting noises from the environment.

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

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

Resonance

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?

Snellen chart

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

Strength of a reflex

A student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed?

The bell of the stethoscope is used to auscultate bowel sounds.

Which is an example of percussion? Select all that apply.

The nurse notes dullness over the client's liver. The nurse notes resonance over the client's thorax. The nurse notes tympany over the client's lower abdomen.

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

Wear clean gloves when administering heparin to the client

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.

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

palpation

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

use as a drape

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?

Hyperresonant

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

A nurse is preparing to conduct an assessment on a client. In what order should the nurse conduct the following actions? Place the steps in the correct order.

Wash hands and don gloves. Take the client's vital signs. Assess eyes, ears, nose, and mouth. Auscultate heart and lung sounds. Assess genitalia

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, d, e, b, a

Light palpation is most appropriate to assess the

inflamed areas of skin

While the nurse is preparing to begin a physical examination of a client, the nurse notes that the bed is in the lowest position, the client is in a side-lying position, the television is on at a loud volume, and the lights are dimmed. How should the nurse proceed with the assessment? Select all that apply.

Adjust the bed to a comfortable height. Ask the client to reposition for the exam as necessary. Lower the bed when the exam is completed.

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

Lungs

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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?

Turn down the volume if the television or radio is on.