PrepU Chapter Three

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?

A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee. Skinfold calipers are used to measure skinfold thickness of subcutaneous tissue. A flexible metric measuring tape may be used for many purposes, including measuring the size of extremities

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

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, nonintact 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 alcohol-based hand rub

The nurse is planning to assess for the presence of lower pitch sounds when examining a patient's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate?

Ensuring client's privacy by providing an examination gown

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

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 Wood's light is used to assess for fungal infections.

The nurse is using the bell of a stethoscope to assess which of the following?

Heart murmurs

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

For which assessment would the nurse plan to use light palpation

Papular rash

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 patient. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

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

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 fingerpads 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

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

an extra blanket

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

bone.

During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing?

lungs

The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use?

newspaper

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

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?

Braden scale

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

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation

Ensure that contact with the skin is maintained

What should the nurse do before conducting a physical examination of a patient?

Identify ways to ensure patient privacy. Obtain and check needed equipment. Ensure a quiet environment. Wash hands.

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

Inspection, palpation, percussion, auscultation 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

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

It is often the source of the most physical signs.

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 to chest

A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?

Lie on the back with legs together on the examination table.

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 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 palpation is a distracter for this question

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

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

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

Ophthalmoscope

A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination

Prone The prone position places the client on the abdomen with the head to the side. This position is used primarily to assess the hip joint. The supine position places the client face up with the legs together, allowing the abdominal muscles to relax and providing easy access to peripheral pulses. Other areas that can be assessed in this position are head, neck, chest, axillae, breasts, abdomen, heart, lungs, and all extremities. The standing position allows examination of balance, posture, and gait. The male genitalia are also assessed in this position. In the dorsal recumbent position, the client lies on the table with the knees bent, the legs separated, and feet flat on the table. Areas that can be assessed are the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses

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?

Resonance A loud, low-pitched hollow sound on percussion is termed resonance and is a typical finding over the lungs, which are part air and part solid tissue. Flatness is a soft, high flat sound typically heard over very dense tissue. Tympany is a loud, high-pitched drum like sound heart over air filled areas. Dullness is a medium, medium-pitched thud like sound heard over more solid tissue

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

Sinuses

A nurse is preparing 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 group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following?

The diaphragm should be held firmly against the body part.

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes. Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

For which patient should the nurse wear gloves to provide care?

The patient with Clostridium difficile The patient with vancomycin-resistant enterococci The patient requiring oropharyngeal suctioning

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?

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

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

Wear clean gloves when administering heparin to the patient

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 which of the following actions?

Wearing gloves to palpate the tongue and buccal membranes

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums

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

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

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?

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

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. 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.

While performing a physical examination on an older adult, the nurse should plan to

use minimal position changes.