PrepU Chapter 3: Collecting Objective Data: The Physical Examination

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision. Explanation: The nurse uses palpation to assess the individual through touch, such as to detect increased warmth surrounding an incision. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting the symmetry of the abdomen. Auscultation is used by the nurse to assess bowel sounds. The nurse detects tympanic sounds of the bowel by percussing the abdomen

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.

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.

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell Explanation: The bell of the stethoscope is used to assess low pitched sounds such as heart murmurs. The bell should be held lightly directly against the skin. The diaphragm of the stethoscope is used to detect high-pitched sounds. It should be held firmly against the client's skin. Even though a thrill may be palpated due to turbulent blood flow, it would have to be a high-grade murmur; therefore, light and moderate palpation would not be used to assess a heart murmur.

The nursing instructor is teaching nursing students about hand hygiene prior to performing a health assessment. The nursing instructor determines effectiveness of the teaching when the students state that hand hygiene should occur at which point? Select all that apply.

before touching a client before eating before leaving a client's room when hands become visibly soiled Explanation: Hand hygiene should occur immediately before touching a client, before and after eating, before leaving a client's room, immediately after (not before) glove removal, and when hands are soiled. Hands must be washed with soap and water when they become visibly soiled.

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

deep palpation. Explanation: Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

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. Explanation: Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.

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

palpation Explanation: Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.

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.

Before beginning a physical assessment of a client, the nurse should first

wash both hands with soap and water. Explanation: A general principle to keep in mind while performing a physical assessment includes washing hands before beginning the examination. If possible, wash hands in the examining room in front of the client. This assures the client that you are concerned about his or her safety

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.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface Explanation: The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The finger pads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus.

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment. Explanation: The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noises from the environment to ensure that the sounds heard are those of the client and not the environment. Using good lighting, preferably sunlight, looking and observing before touching the client, and comparing the appearance of symmetric body parts are some of the guidelines to perform the technique of inspection.

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.

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

Low-frequency sounds Explanation: The bell is used with light skin contact to hear low-frequency sounds.

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?

Adequate lighting Explanation: Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination

A nurse is preparing to evaluate an older 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?

Braden scale Explanation: The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores. The Snellen E chart is used to test distant vision. The penlight is used to view the mouth and throat and to transilluminate the sinuses. The reflex (percussion) hammer is used to test tendon reflexes.

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Complete the forgotten portion of the exam out of sequence. Explanation: The nurse should complete the forgotten portion of the exam out of sequence. It is not appropriate to proceed without complete assessment data, and collecting the missing data at the end of the shift is not part of a timely assessment. This initial assessment provides baseline data for comparison during the remainder of the shift. Informing the client that the examination was incomplete and starting over from the beginning of the assessment is not necessary.

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer Explanation: If a client requests that a certain part of the examination, such as the breast examination, not be performed, the nurse should explain the importance of the examination and the risk of missing important information if any part is omitted. Simply complying with the client's request, insisting on the examination, and asking the physician to perform it would not be appropriate actions.

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.

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?

Hyperresonant Explanation: A hyperresonant lung sound is very loud, low in pitch, long in duration, and booming in quality. This is the sound heard from emphysematous lungs.

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 Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate is not typically used to describe palpation.

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

Limit position changes as much as possible Explanation: Client safety is paramount. For a client who has general muscle weakness, the risk for falls and injury is high. It should be considered the priority to limit position changes during the examination as much as possible. Infection control through washing hands and equipment is important; however, in this case limiting position changes is the priority. Draping body areas not being assessed is needed to ensure client privacy and prevent chilling, however, prevention of a fall must be prioritized due to the client's risk factors.

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?

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.

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 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.

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. Explanation: Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the client to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the client in the lying position.

What would be the expected tone elicited by percussion of a normal lung?

Resonance Explanation: Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue.

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.

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.

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?

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.

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.

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

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

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b.Groin, hips, and knees c.Breasts d.Chest and thorax e.Cardiovascular

c, d, e, b, a Explanation: When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.