Health Assessment PrepU Chapter 3
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, non-intact 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 antiseptic handrub
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?
Dorsal hand surface
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.
When assessing pulses, the nurse would use which part of the hand for palpation?
Fingerpads
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?
Fungal infection
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 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
What's included in personal protective equipment? Select all that apply.
Gown Gloves Mouth, nose, eye protection
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
What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?
Latex allergy
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 recognizes that it is best to begin the objective data collection with what procedure?
Measure the client's vital signs, height, and weight
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
The nurse wears gloves to:
Prevent transmission of flora from patient to patient.
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
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
A client with a 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
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.
While examining a client, the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand.
The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?
peripheral vascular
