Chapter 9 Techniques and Equipment

The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment? 1. Percussion. 2. Palpation. 3. Transillumination. 4. Auscultation.

Correct Answer: 1 After auscultating the client's abdomen, the nurse would begin percussion.

A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more detailed neurological assessment of this client? 1. Asymmetry of the client's smile. 2. Grimacing with movement. 3. Talking in a loud voice. 4. Inability to follow directions.

Correct Answer: 1 Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves.

The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. Which action by the nurse is appropriate in this situation? 1. Checking the pressure applied to the probe. 2. Adding more gel to the end of the probe. 3. Informing the healthcare provider immediately. 4. Sending the equipment for repair.

Correct Answer: 1 Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client's skin, over the artery to be auscultated.

The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which should the nurse incorporate into the physical assessment of this client? Select all that apply. 1. Washing hands in the presence of the client. 2. Putting on nonsterile gloves to examine the client. 3. Ensuring that the client has an empty bladder before beginning the physical assessment. 4. Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. 5. Assessing only the left lower extremity since this is the injured body part.

Correct Answer: 1, 2

When is it appropriate for the nurse to use an otoscope during a physical assessment? Select all that apply. 1. Inspecting the nose. 2. Funneling light into the ear canal. 3. Inspecting the internal structures of the eye. 4. Assessing pulses that are not palpable. 5. Detecting fungal infections of the skin.

Correct Answer: 1, 2

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? Select all that apply. 1. The stethoscope works by blocking out environmental sounds. 2. Short tubing provides the listener with the most accurate sounds. 3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. 4. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection. 5. The binaurals should fit snugly in the ears.

Correct Answer: 1, 2, 5

The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child? Select all that apply. 1. Putting on nonsterile gloves prior to assessing the child's injuries. 2. Disposing of blood-soaked gauze in the office trash bin. 3. Performing handwashing before touching the child. 4. Asking the child permission to assess the injuries. 5. Wearing a mask while washing the child's abrasions.

Correct Answer: 1, 3, 4

During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate? 1. Document this as abnormal. 2. Wet the chest hair before auscultating the chest. 3. Place the diaphragm on top of the client's shirt. 4. Switch from the diaphragm to the bell.

Correct Answer: 2 Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client's chest before auscultation.

The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which action by the nurse is appropriate when palpating this client's abdomen? 1. Assessing the painful area first using moderate palpation. 2. Assessing the painful area last using deep palpation. 3. Assessing the painful area last using light palpation. 4. Assessing the painful area first using deep palpation.

Correct Answer: 2 Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation.

A client has a reddened area on the left forearm. Which assessment technique should the nurse use to assess this area? 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation.

Correct Answer: 2 Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.

While percussing a client's lung area the nurse notes a resonance. What does the tone indicate? 1. The nurse is percussing over a bone. 2. A normal finding. 3. The lungs are solidified. 4. Air is trapped in the lungs.

Correct Answer: 2 Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance.

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment? 1. Downward pressure of 1-2 cm using the finger pads. 2. Side to side pressure of ½-1 cm using the finger pads. 3. Downward pressure of 2-4 cm using the palmar surface of the fingers 4. Light pressure using the base of the fingers (metacarpophalangeal joints).

Correct Answer: 2 Side-to-side palpation of ½-1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node).

The nurse is unable to palpate a client's pedal pulses. Which item will the nurse use to assess this client's pedal pulses? 1. Stethoscope. 2. Doppler. 3. Transilluminator. 4. Goniometer.

Correct Answer: 2 The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses.

The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority? 1. Give the client a short break and then resume the assessment. 2. Document what was done and what was refused. 3. Summon another nurse to the room to serve as a witness. 4. Enlist the assistance of the client's family to encourage the rest of the assessment.

Correct Answer: 2 The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused.

The nurse is planning to perform a physical assessment on an adult client. Before beginning this phase of the client's health assessment, which action by the nurse is the most appropriate? 1. Provide a gown for the client to change into. 2. Explain to the client what will happen during the examination. 3. Obtain a written consent. 4. Wash hands in the presence of the client.

Correct Answer: 2 The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client's anxiety and enlists the client's cooperation with the assessment.

The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which color is visualized through the red-free filter of the ophthalmoscope? 1. Green. 2. Black. 3. Red. 4. Yellow.

Correct Answer: 2 The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black.

The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. Which technique is appropriate for the nurse to use when assessing this client's abdomen? 1. Palpating known painful areas first. 2. Touching each area lightly before applying deeper palpation. 3. Performing the exam as quickly as possible. 4. Refraining from conversation during the assessment.

Correct Answer: 2 Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction.

The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. Select all that apply. 1. Putting on nonsterile gloves. 2. Providing an opportunity for the client to void. 3. Washing hands in the presence of the client. 4. Turning on soft music to relax the client. 5. Ensuring adequate light in the room.

Correct Answer: 2, 3, 5

The nurse is inspecting a client's chest and upper extremities. Which would be the appropriate method for the nurse to assess these body areas? 1. Examine the right arm, the chest, and then the left arm. 2. Examine the left arm, the chest, and then the right arm. 3. Examine the left arm, the right arm, and then the chest. 4. Examine the chest, and then examine the arms at the conclusion of the exam, as the client is re-dressing.

Correct Answer: 3 Inspection begins with a survey of the client's appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest.

The nurse is preparing to percuss the lower lobes of a client's lungs. Which percussion technique is the most appropriate for the nurse to use during this assessment? 1. Direct percussion. 2. Blunt percussion. 3. Indirect percussion. 4. Any of the percussion techniques.

Correct Answer: 3 Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used.

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate? 1. Informing the client of "the abnormality." 2. Stopping the assessment and referring the client to the healthcare provider immediately. 3. Bring in another examiner to assess the finding. 4. Documenting the finding and reassessing at the client's next visit.

Correct Answer: 3 The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse's unfamiliar finding.

The nurse is assessing a client's right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client's skin? 1. Fingertips. 2. Metacarpophalgeal joints. 3. Dorsal surface. 4. Ulnar surface.

Correct Answer: 3 The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature.

The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment? 1. Loud, low-pitched. 2. Soft, high-pitched. 3. Drum-like. 4. Abnormally loud.

Correct Answer: 3 Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines.

A client has a visible pulsation in the middle of his abdomen. Which assessment technique is appropriate for the nurse to use to assess this pulsation? 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation.

Correct Answer: 3 With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present.

The nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination? 1. An adult client with flu symptoms. 2. A preschool-age client in for a well check-up. 3. An adolescent client who complains of fatigue. 4. An older adult client with chronic lung disease.

Correct Answer: 4 Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion.

While auscultating a client's lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate? 1. Obtain a stethoscope with longer tubing. 2. Ask another nurse to listen to the lung sounds. 3. Hold the stethoscope tubing while listening to the lung sounds. 4. Close the eyes and focus on one sound at a time.

Correct Answer: 4 Closing the eyes and concentrating on each sound may help the nurse focus on the sound.

The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment? 1. Using the hyperextended middle finger of the nondominant hand. 2. Using the closed fist of dominant hand. 3. Using the palm of the nondominant hand. 4. Using the fingertips of the dominant hand.

Correct Answer: 4 Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult client.

The nurse is preparing to assess a client's abdomen. Place the sequence for an abdominal assessment is the correct order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Percussion. Response 2. Palpation. Response 3. Auscultation. Response 4. Inspection.

Correct Answer: 4, 3, 1, 2

The nurse educator is teaching a group of nursing students the correct assessment of heart murmurs. Which part of the stethoscope will the educator press against the client's chest during this assessment?

Correct Answer: B The bell of the stethoscope is used to assess murmurs.

The nurse educator is demonstrating the proper technique for assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate proper technique?

Correct Answer: C Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.