Chapter 3 - Collecting Objective Data

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

- gloves - gown - mouth, nose, and eye protection

Physical examination

1. inspection 2. palpation 3. percussion 4. auscultation

The correct depth for light palpation is:

1cm

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

Alcohol-based rub

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

Dorsal surface

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 female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?

Explain to the client why the assessment is important and the possibility of missing important findings.

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?

Heart murmur

A new RN is now performing the examination of an abdomen. What order of examination techniques would be correct?

Inspection, auscultation, percussion, palpation

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

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

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

Which illustrates the nurse using the technique of inspection?

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

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 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

Which part of the hand is best for assessing temperature?

dorsa/back of the hand

Before beginning the inspection of a patient, you should perform what action?

ensure the patient's privacy

The part of the hand used to assess find discrimination (pulses, lymph nodes, small lymph nodes, assessing skin texture and edema) is called _____

finger pads

The most commonly used type of percussion is:

indirect percussion

Light palpation is most appropriate to assess the

inflamed ares of skin

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

inspection

_____ involves using the sense of vision, smell, and hearing to observe and detect any normal or abnormal findings

inspection

Percusssion

involves tapping body parts to produce sound waves and vibrations

Inspection

involves using the sense of vision, smell, and hearing to observe and detect any normal or abnormal findings

Types of palpation

light, moderate, deep, bimanual

You are preparing to palpate a patient's abdomen during a comprehensive assessment. You will likely use which part of your hand?

palm

When you conduct an inspection, what should you take note of?

size, color, shape, position, and symmetry

Palpation

using parts of the hand to touch and feel: texture, temperature, moisture, mobility, consistency, strength of pulse, size, shape, and degree of tenderness

Which statement best describes an aspect of the nursing assessment process?

"The assessment process is ongoing and is not linear"

The nursing instructor is teaching nursing students about hand hygiene prior to performing a health assessment. The nursing instructor determines effectiveness of the teaching when the students state that hand hygiene should occur at which point? Select all that apply.

- before touching a client - before eating - when hands become visibly soiled

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

- obtain and check needed equipment - identify ways to ensure client privacy - wash hands

Sounds elicited by percusssion

- resonance - hyperresonance - tympany - dullness - flatness

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

Types of percusssion

direct, blunt, indirect or mediate

During assessment of the patient's abdomen, you should auscultate immediately after performing palpation

false

The diaphragm of the stethoscope is used to listen to low-pitched sounds, such as abnormal heart sounds and bruits

false

_____ involves tapping the body parts to produce sound waves

percussion

When performing blunt percussion during an assessment, you should begin by:

placing your palm flat against the patient's skin

When using the stethoscope for auscultation, how should the nurse position the earpieces?

pointed toward the nose

How do nurses facilitate high-level wellness achievement with a patient?

promoting health

Auscultation

requires use of stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of bowel and movement of air through the respiratory tract

The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following?

resonance

During inspection, it is preferable to use sunlight, because fluorescent lights can alter the true color of the skin

true

The depth of the structure being palpated and the thickness of the tissue overlying the structure determine whether one should light, moderate, or deep palpation

true

Whether to have a physical examination ultimately rests with the client, even though the nurse might have informed the client about the importance of such an examination

true

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.

- right calf appears red - right calf is warm to touch - client grimaces when dorsiflexing the right calf

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

- the nurses notes a fine rash covering the individual's thorax - the nurses notes a symmetry of the individual's thorax - the nurse detects foul odor of the urine

What steps should you take when documenting and assessing inspection findings? Select all that apply.

- use correct medical terminology to describe and document findings - note normal and abnormal findings - compare inspection findings with verbal and nonverbal cues - identify any patterns or clusters of findings

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

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?

Resonance

When percussing over dense tissue or bone, the nurse will hear flatness. Describe what flatness sounds like.

flatness is soft in volume and high-pitched

The process of health assessment begins with what activity?

gathering information from the patient

You are assessing a 32-year-old woman with unexplained lesions on her back. You are going to palpate the area of the lesions. What type of palpation should you use?

light

When auscultating the patient's respiratory system, which action should you perform?

listen to one full breath in each location where you place your stethoscope

The bell of the stethoscope is best used to hear:

low-pitched sounds

_____ data include information about the client that the nurse directly observes during interaction with them and information elicited through physical assessment techniques

objective

When auscultating a patient's abdomen, a nurse notes gurgling sounds. What characteristic of sound would the nurse document?

quality

Which describes the nurse using the technique of percussion?

the nurse notes resonance over the individual's thorax

You perform percussion during an assessment, and the procedure causes the patient pain. What is the most likely indication of this finding?

there is inflammation in an underlying structure

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?

to determine any changes from the baseline data

What is the primary purpose of a health assessment?

to gather information about the health status of the patient

What palpation category does this description fall under: depressing the palmar surface of your fingers 1 to 2 cm deep into the surface structure in order to assess firmness, contour, position, size, pain, and tenderness of the structure?

moderate palpation

_____ consists of using the parts of the hand to touch and feel for characteristics such as texture, temperature, moisture, and mobility

palpation

While beginning assessment of a patient's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?

the diaphragm

A nurse-client relationship established before a physical examination helps to alleviate tension or anxiety that the client is experiencing

true

A young man has presented to the clinic with a two-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness?

direct percussion

A(n) _____ is used to listen for heart sounds, movement of the bowel, and the movement of air through the respiratory tract, which are not audible to the human ear

stethoscope