Health Assessment Chapter 3 Practice Questions

Purposeful hourly rounding by the nurse should include which assessments? (Select all that apply.)

- Pain - Personal needs - Position - Fall prevention

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

Bone

What can the nurse assess using percussion?

Borders of the heart

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 Explanation: A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee.

The most commonly used method of percussion is

Indirect percussion Explanation: Indirect or mediate percussion is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures.

What assessment technique is performed for every body part and body system?

Inspection

As the density of tissue decreases, the percussion note becomes:

Lower pitched

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

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 describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

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

Wearing gloves when palpating the tongue, lips, & gums

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

light palpation

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.

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

- wash hands before and after client contact - change white coat frequently

The nurse wears gloves for which of the following purposes? Select all that apply.

-Prevent transmission of flora from client to client. -Limit exposure to body fluids and secretions

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

1.5 inch diaphragm

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

Auscultation Explanation: During the abdominal examination, the pattern will be inspection, auscultation, percussion, and palpation. Auscultation follows inspection so as not to increase bowel motility with palpation.

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

Blunt percussion

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?

Examining the tongue

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?

Hyperresonance

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

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 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

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.

What is the nurse's primary role in subjective data collection?

To improve the client's health status

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

Strength of a reflex

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.- Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the patient's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

What is the principle of percussion?

To create vibration in a body wall

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system Explanation: The tuning fork is used with two body systems: to determine vibration sense in the neuromuscular system and to determine conductive versus sensorineural hearing loss in the ears.

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

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

ophthalmoscope

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

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

up and back

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

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

Indirect percussion: Explanation: Indirect percussion ensures that the client does not receive direct strikes to the body part being examined. Direct percussion might be painful when assessing the abdomen. Percussion is not divided into direct and indirect approaches.

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

Sinuses Explanation: The nurse performs direct percussion by tapping the fingers directly on the client's skin, such as for assessment of the sinuses. The nurse performs indirect percussion by using the non-dominant hand as a barrier between the nurse's dominant hand and the client to assess organs, such as the gallbladder, kidneys, and liver.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion Explanation: Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.