HEALTH ASSESSMENT CHAPTER THREE (3) PREP U

palpation

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

Gown Face shield Gloves

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.

Measure the client's vital signs, height, and weight.

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

Ophthalmoscope

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

Light palpation

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

deep palpation

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

Up and back

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

Heart sounds

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?

Inspection, palpation, percussion, auscultation

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

inflamed areas of skin

Light palpation is most appropriate to assess the

goniometer

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?

False

The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.

Hand hygiene

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

Fungal infection

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

peripheral vascular

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

Alcohol-based rub

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

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

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

Hyperresonant

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?

Latex allergy

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

The nurse detects gurgling throughout the abdomen

Which describes the nurse using the technique of auscultation?

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

Which illustrates the nurse using the technique of inspection?

dorsal surface of the hand.

While examining a client, the nurse plans to palpate temperature of the skin by using the

"They make sure that any microorganisms on my hands do not touch your skin."

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

Collect necessary equipment essential to the exam

A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam?

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?

Skin lesion size

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

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?

Wood's light

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?

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?

Braden scale

A nurse is preparing to evaluate an elderly client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

Skinfold calipers

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?

The diaphragm should be held firmly against the body part.

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

Rub the hands and fingers until dry

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub?

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?

Gloves, mask, protective eye goggles, gown

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?

Risk for injury

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?

Ensuring client's privacy by providing an examination gown

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

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?

hyperresonance

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

inspection

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

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?

Sinuses

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

Papular rash

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

Wet the hands. Apply soap. Scrub the hands together vigorously for 15 seconds. Rinse the hands. Dry hands Turn off faucet with paper towel.

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last.

Pay attention to the details while observing

The admitting nurse has just met a new client. As the nurse introduces himself, he begins the process of inspection on this client. What does the admitting nurse know it is important to do while observing during the process of inspection?

Wear clean gloves when administering heparin to the client

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

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?

Resonance

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

stethoscope bell

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?

Try to minimize position changes.

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate?

Temperature

The nurse places the back of the hand on forehead of a client. What is the nurse assessing when using this part of the hand?

Light palpation

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

Dorsal hand surface

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

An extra blanket

When performing a physical assessment on an older adult client, what should the nurse consider offering this client?

It is often the source of the most physical signs.

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

Palpation Inspection Auscultation

Which of the following techniques are used in a physical assessment? Select all that apply.

bone

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

percussion

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

Palpation

You are performing a shift assessment as you begin caring for one of your clients. What is the most effective assessment technique for the lymph nodes of the neck?

Low-frequency sounds

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

Feeling the surface structures using a circular motion

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action?

Use the middle finger to deliver two taps

The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?

Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate?

Color

A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?

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?

Coin or key

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