Health Assessment PrepU Ch. 6 (Physical Examination)
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 Explanation: The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds.
A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?
Inspection, palpation, percussion, auscultation Explanation: Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?
Inspection, palpation, percussion, auscultation Explanation: Inspection is the first physical assessment technique that a nurse should implement. This prevents altering the appearance of structures that may distract the nurse from completing a focused observation.
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 Explanation: The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpation is used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?
Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.
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 Explanation: To assess the client's breathing sounds, the nurse auscultates the lungs using the stethoscope.
A nurse recognizes that it is best to begin the objective data collection with which procedure?
Measure the client's vital signs, height, and weight Explanation: It is important to begin the assessment with less intrusive procedures such as vital signs and height & weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed.
What steps are involved in the client-to-client transmission of pathogens? (Select all that apply.)
Organisms are transferred from the client to the nurse's hands The nurse's contaminated hands come into direct contact with another client Organisms are present in the client's immediate environment Explanation: Patient-to-client transmission of pathogens requires five sequential steps: (1) Organisms are present on a client's skin or immediate environment; (2) Organisms are transferred from the client to the nurse's hands; (3) Organisms survive on the nurse's hands for at least several minutes; (4) The nurse omits or performs inadequate or inappropriate hand hygiene; (5) The nurse's contaminated hands come into direct contact with another client or environment in direct contact with the client. The use of alcohol-based hand sanitizer breaks the five-step process. Organisms can live on the nurse's hands for more than 1 minute if not cleansed appropriately.
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 Explanation: The nurse wears gloves to prevent transmission of flora from client to client, prevent exposure to body fluids and secretions, decrease the risk of the nurse acquiring infection from the client, and reduce contamination of the hands of the nurse.
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?
Skin lesion size Explanation: A centimeter scale rule most likely would be used to measure the size of a skin lesion. A flexible tape measure would be appropriate to measure mid-arm circumference. A vertical scale in inches or meters would be appropriate to measure a client's height. Pupil size is measured in millimeters.
It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?
Skin lesion size Explanation: A centimeter scale rule most likely would be used to measure the size of a skin lesion. A flexible tape measure would be appropriate to measure mid-arm circumference. A vertical scale in inches or meters would be appropriate to measure a client's height. Pupil size is measured in millimeters.
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 Explanation: Skinfold calipers measure skinfold thickness of subcutaneous tissue to aid in establishing a client's percent body fat. A platform scale with height attachment measures height and weight. A metric ruler is used to measure the size of skin lesions. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.
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 Explanation: To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A penlight is used to test pupillary constriction.
Which illustrates the nurse using the technique of inspection?
The nurse detects a fruity odor of the client's breath. Explanation: Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the client'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.
Which describes the nurse using the technique of auscultation?
The nurse detects gurgling throughout the abdomen. Explanation: Auscultation is used by the nurse to assess bowel sounds, such as gurgling throughout the abdomen. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors, such as foul smelling urine. The nurse uses palpation to detect nodules in the breast by the use of touch. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as dullness over the liver.
Which is an example of inspection? Select all that apply.
The nurse notes a fine rash covering the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects foul odor of the urine. Explanation: Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a foul odor to the client's urine and note rashes and symmetry of the thorax. The nurse uses the technique of palpation to detect masses. Auscultation is used by the nurse to assess lung sounds, such as crackling.
Which describes the nurse using the technique of percussion?
The nurse notes resonance over the individual's thorax. Explanation: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.
While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?
To determine whether a structure is filled with air or fluid or is a solid structure Explanation: The nurse uses the percussion technique while performing a physical examination to determine whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is used to feel deep organs or structures covered by thick muscles and to determine tenderness, moisture, and surface skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface.
The nurse is caring for the client who is receiving heparin. The nurse plans to:
Wear clean gloves when administering heparin to the client Explanation: Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.
A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action?
Wearing gloves to palpate the tongue and buccal membranes Explanation: When adhering to standard precautions, the nurse would wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a client incontinent of stool or urine) could occur. Safety pins should be disposed of in the sharps container. Gowns and masks are appropriate only if anticipated client interaction indicates that contact with blood or body fluids may occur. Hand hygiene need not be performed between assessments of each system or body part.
Which action by a nurse demonstrates the correct application of the principles of standard precautions?
Wearing gloves when palpating the tongue, lips, & gums Explanation: The nurse should wear gloves when examining or touching any areas where there is the potential for exposure to blood or body fluids. Gloves are changed between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Wearing a gown, gloves, and mask is not necessary for the entire physical assessment. If hands are visibly soiled, the nurse should wash with soap and water.
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 Explanation: Wood's light is a special piece of examination equipment that is used to test for fungus. A penlight is used for more general assessments, such as of the mouth and throat and to transilluminate the sinuses. A magnifying glass is used to enlarge the visibility of a lesion. An examination light is used to better illuminate the client's body as a whole to facilitate physical examination.
The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?
goniometer Explanation: A goniometer is used to measure degree of flexion and extension of joints. A speculum is used to examine the ear canals. Test tubes are used to measure temperature sensation. A stadiometer is used to measure height.
During a comprehensive assessment, the primary technique used by the nurse throughout the examination is
inspection. Explanation: Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.
The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?
peripheral vascular Explanation: A tuning fork has two uses in the physical examination. The most common is to assess hearing however the tuning fork is also used to assess the sense of vibration when completing the neurologic or peripheral vascular assessment. A tuning fork is not used to assess the respiratory, genitourinary or gastrointestinal systems.
A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?
reflex hammer Explanation: A reflex is used to assess deep tendon reflexes which are under the control of the neurologic system. A penlight is used to assess pupillary reflexes and aids with tangential lighting. A scoliometer measures the degree of spinal curvature. A pulse oximeter measures oxygen level.
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 Explanation: During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.
A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?
"They make sure that any microorganisms on my hands do not touch your skin." Explanation: One reason to wear gloves is to prevent the transmission of flora from health care workers to clients. Wearing gloves is more than just following a policy. Gloves hinder the ability to discern body parts and positions. Although the client may have a communicable illness, the nurse should not make a statement that could cause the client anxiety about being ill.
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
Disinfect the stethoscope before touching the client Explanation: The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens. Disinfecting the stethoscope after touching the client does not answer the question being asked. Placing the stethoscope directly on the client's skin does not answer the question being asked. Nothing noted in the question would require the nurse to wear a personal protection gown.
The nurse would use what part of the hand when assessing temperature during palpation?
Dorsal surface Explanation: The dorsal surface is used for temperature. The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus.
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?
Ensuring client's privacy by providing an examination gown Explanation: The client is usually concerned about unnecessary body exposure. Explanation and reassurance that the nurse will protect the client's privacy decreases this anxiety. Providing a comfortable, warm room temperature is appropriate to prevent chilling, but is usually less important to the client than privacy. Arranging exam equipment on a bedside tray table if within the view of the client may add to the client's anxiety. However, arranging the exam equipment would facilitate organization. Explaining why standard precautions are being used may help alleviate some anxiety, but the client probably will not understand what standard precautions are.
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?
Ensuring that contact with the skin is maintained Explanation: While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.
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?
Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. Explanation: The nurse should explain to the client the importance of the examination and the risk of missing important information if any part is omitted. However, whether or not to have the examination is the client's decision and must be respected.
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?
Explanation: Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as
When assessing pulses, the nurse would use which part of the hand for palpation?
Finger pads Explanation: The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus. The dorsal surface is used for temperature.
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.
Gloves Gown Face shield Explanation: The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure.
What included in personal protective equipment? Select all that apply.
Gloves Gown Mouth, nose, eye protection Explanation: Personal protective equipment (PPE) includes gloves, gown, mouth, nose and eye protection. Special linen and cleaning processes are not part of PPE.
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 Explanation: Because this client has emphysema with a chronic productive cough, it is likely that the nurse will not only come into direct contact with the client's sputum or mucus (a body fluid) during examination of his oral cavity, which requires the use of gloves, but also that sputum will be sprayed on the nurse's face and body, which requires the use of a mask, protective eye goggles, and a gown.
When caring for clients in any health care environment, what is the most important technique for preventing infection?
Hand hygiene Explanation: The single most important action to prevent infection is hand hygiene. Sterile technique is important in preventing infection in invasive procedures, but the questions does not address the specific situation of invasive procedures, only infection in general. Standard precautions and the use of gloves prevent a healthcare provider from being exposed to blood and body fluid while caring for a client. This is important in the infection cycle, but is not the most important technique.
The nurse is preparing for a physical examination of a client. What should the nurse do first?
Hand hygiene Explanation: The nurse should perform hand hygiene before beginning the physical assessment. This includes prior to gathering equipment. Auscultation and palpitation should not occur until after hand hygiene has been performed.
What is used to gauge central and peripheral nervous system disorders?
Strength of a reflex
What assessment technique is performed for every body part and body system?
Inspection Explanation: Inspection is the one technique that is performed for every body part and body system. Other techniques are not used for every body part and system.
How should the nurse place the ear of an adult when using the otoscope?
Up and back
