Physical Assessment Scenerios Chapter 3: Techniques of Assessment and Safety

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? A) Measure the client's vital signs, height, and weight. B) Begin at the head and move in a systematic approach. C) Auscultate all necessary body systems to prevent disturbing any organs. D) Allow the client to undress and put on a gown.

A) 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 and 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.

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? A) Auscultation can be performed through clothing. B) The diaphragm should be held firmly against the body part. C) The bell of the stethoscope can detect bowel sounds. TD) he binaurals connect the tubing to the chest piece.

B) The diaphragm should be held firmly against the body part. Explanation: The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing.

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? A) Nonantimicrobial soap and water with friction B) Hand wash with antiseptic soap C) Application of an antiseptic hand rub D) No washing is needed because hands are not soiled

C) Application of an antiseptic hand rub Explanation: The nurse could apply an antiseptic hand rub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? A) Abdomen B) Neck C) Lungs D) Back

C) Lungs Explanation: To assess the client's breathing sounds, the nurse auscultates the lungs using the stethoscope.

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? A) Auscultation, percussion, palpation, inspection B) Percussion, palpation, inspection, auscultation C) Palpation, inspection, auscultation, percussion D) Inspection, palpation, percussion, auscultation

D) 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.

For which of the following assessments would the nurse plan to use light palpation? A) Skin temperature B) Skin texture C) Skin rash D) Shape of abdominal mass E) Size of liver

A) Skin temperature B) Skin texture C) Skin rash Explanation: Light palpation is used to assess surface characteristics, such as a papular rash. Deep palpation is used to assess the size, shape, and consistency of abdominal organs.

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last. 1. Rinse the hands. 2. Apply soap. 3. Turn off faucet with paper towel. 4. Wet the hands. 5. Dry hands 6. Scrub the hands together vigorously for 15 seconds.

1) Wet the hands. 2) Apply soap. 3) Scrub the hands together vigorously for 15 seconds. 4) Rinse the hands. 5) Dry hands 6) Turn off faucet with paper towel.

The nurse would use what part of the hand when assessing temperature during palpation? A) Dorsal surface B) Finger pads C) Ulnar surface D) Palmar surface

A) 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.

The nurse is caring for the client who is receiving heparin. The nurse plans to: A) Wear clean gloves when administering heparin to the client B) Recap the needle after administering heparin to the client C) Perform hand hygiene with alcohol-based gel after administering the heparin D) Wear a mask when administering heparin to the client

A) 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 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? A) penlight B) scoliometer C) reflex hammer D) pulse oximeter

C) 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.

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? A) Platform scale with height attachment B) Metric ruler C) Sphygmomanometer D) Skinfold calipers

D) 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 nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? A) Light palpation B) Moderate palpation C) Deep palpation D) Bimanual palpation

A) 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.

Which measure does the nurse take to prevent transmission of organisms? A) Maintains fingernails to ¼ inch or shorter. B) Vigorously scrubs hands together for 30 seconds. C) Uses alcohol-based hand gel for visibly soiled hands. D) Uses clear polish on artificial nails.

A) Maintains fingernails to ¼ inch or shorter. Explanation: The nurse maintains fingernails to ¼ inch or shorter to prevent transmission of organisms. The Centers for Disease Control and Prevention recommends the nurse use soap and water for visibly soiled hands, vigorously scrub hands together for 15 seconds, and not wear artificial nails.

Which illustrates the nurse using the technique of inspection? A) The nurse detects a fruity odor of the client's breath. B) The nurse notes increased warmth surrounding the client's incision. C) The nurse notes a rhythmic lub-dub over the client's anterior thorax. D) The nurse detects tympany over the client's lower abdomen.

A) 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.

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? A) Turn down the volume if the television or radio is on. B) Turn down the lights in the room. C) Ensure that the client is lying down. D) Ask the client to take deep breaths.

A) Turn down the volume if the television or radio is on. Explanation: When completing a manual blood pressure assessment, it is important to ensure that external noise does prevent the nurse's ability to hear the systolic and diastolic blood pressure sounds. Turning the television volume down assists the nurse in obtaining a more accurate measurement of the blood pressure. Turning down the lights in the room could prevent the nurse from being able to read the blood pressure accurately. The client may sit or lie down; having the client lie down is not necessary for an accurate reading. Asking the client to take deep breaths would promote relaxation; however, it would not improve the accuracy of the assessment.

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. A) Nasopharyngeal airway B) Gloves C) Gown D) Face shield E) Stethoscope

B) Gloves C) Gown D) 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.

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? A) Inspection B) Palpation C) Percussion D) Auscultation

B) Palpation Explanation: Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.

Your lab instructor explains that physical examination relies on what cardinal assessment technique? A) Assessment B) Percussion C) Organization D) Communication

B) Percussion Explanation: Note that the physical examination relies on four classic techniques: inspection, palpation, percussion, and auscultation.

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's A) lungs. B) bone. C) liver. D) abdomen.

B) bone. Explanation: Flatness is a sound heard over very dense tissue like bone.

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client? A) "It's a policy I have to follow." B) "They help me feel your body parts under your skin better." C) "They make sure that any microorganisms on my hands do not touch your skin." D) "Since we don't know what's wrong with you, I wear gloves to make sure I don't get sick."

C) "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.

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment? A) Feel for deep organs or structures covered by thick muscles B) Determine tenderness, moisture, and the surface of skin texture C) Determine if a structure is filled with air or fluid or is a solid structure D) Observe for abnormalities on the skin's surface

C) Determine if 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 in order 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 of skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface.

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population? A) Bunions B) Inflamed skin C) Latex allergy D) Medication allergies

C) Latex allergy Explanation: Latex allergies are more common in nurses and clients frequently hospitalized. Research shows the risk of developing a latex allergy is increased in individuals with increased latex exposure. Nurses and clients who are often hospitalized are not more frequently diagnosed with bunions, inflamed skin, or medication allergies.

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? A) respiratory B) genitourinary C) gastrointestinal D) peripheral vascular

D) peripheral vascular 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.