1.
When Mr. Espero performed the exam on the 73-year-old male, he observed the client in a deliberate and systematic manner. What type of technique did Mr. Espero use?
Correct Answer
B. Inspection
Explanation
Mr. Espero used the technique of inspection. Inspection involves visually examining the client in a deliberate and systematic manner. It is the first step in a physical examination and involves observing the client's body, movements, and overall appearance for any abnormalities or signs of illness. This technique does not involve touching or listening to the client's body, but rather relies on visual cues to gather information.
2.
When Mr. Espero is performing the eye examinations, which piece of equipment does he use to inspect the eye structures?
Correct Answer
D. Ophthalmoscope
Explanation
Mr. Espero uses an ophthalmoscope to inspect the eye structures during eye examinations. An ophthalmoscope is a medical device that allows the doctor to examine the interior structures of the eye, such as the retina, optic nerve, and blood vessels. It consists of a light source and a magnifying lens, which helps to visualize the eye structures and detect any abnormalities or signs of diseases. The ophthalmoscope is an essential tool for ophthalmologists and optometrists to assess the health of the eyes and diagnose various eye conditions.
3.
Throughout the physical assessment, the professional nurse is required to apply the principles of asepsis.
Correct Answer
A. True
Explanation
Asepsis refers to the practice of preventing the introduction or spread of infection. In a healthcare setting, it is crucial for a professional nurse to apply the principles of asepsis during physical assessments to minimize the risk of infection transmission to patients. This includes following proper hand hygiene protocols, using sterile techniques when necessary, and maintaining a clean and sanitized environment. Therefore, the statement that the professional nurse is required to apply the principles of asepsis throughout the physical assessment is true.
4.
When Mr. Espero is evaluating a 3-year-old child, it is not necessary for the client’s parents to sign a permit for the examination.
Correct Answer
B. False
Explanation
When evaluating a 3-year-old child, it is necessary for the client's parents to sign a permit for the examination. This is because the child is a minor and cannot provide consent on their own. The parents or legal guardians must give permission for any medical or evaluative procedures involving the child. Therefore, the statement "it is not necessary for the client's parents to sign a permit for the examination" is false.
5.
The nurse is completing a head-to-toe assessment of the client. When the nurse is assessing the eye, the otoscope is used to perform the assessment.
Correct Answer
B. False
Explanation
The otoscope is not used to assess the eye during a head-to-toe assessment. The otoscope is typically used to assess the ear canal and tympanic membrane. To assess the eye, the nurse would typically use a penlight or ophthalmoscope to examine the external structures of the eye, such as the eyelids, conjunctiva, and sclera.
6.
The nurse is preparing to assess a 55-year-old female. Which of the following will the nurse do first?
Correct Answer
A. Inspection
Explanation
The nurse will first perform inspection when assessing a 55-year-old female. Inspection involves visually examining the patient's body and assessing for any abnormalities, such as skin color, wounds, or swelling. This initial step allows the nurse to gather important information about the patient's overall appearance and any visible signs of illness or injury. By conducting inspection first, the nurse can then proceed with the other assessment techniques, such as percussion, palpation, and auscultation, to gather more specific information about the patient's condition.
7.
A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which assessment technique to find out more information about this complaint?
Correct Answer
C. Palpation
Explanation
The nurse will utilize palpation to find out more information about the client's complaint of swollen ankles. Palpation involves using the hands to touch and feel the body, allowing the nurse to assess for any abnormalities, tenderness, or swelling. By palpating the ankles, the nurse can gather information about the extent of the swelling, the texture of the skin, and any associated pain or discomfort. This assessment technique helps the nurse gather important data to further evaluate the client's condition and determine appropriate interventions.
8.
A client comes into the clinic with acute right lower quadrant abdominal pain. During the abdominal assessment of this client, the nurse realizes that:
Correct Answer
B. This area should be palpated last.
Explanation
The correct answer is "This area should be palpated last." When a client presents with acute right lower quadrant abdominal pain, it is important to palpate this area last because it can be indicative of appendicitis. Palpating this area earlier in the assessment can potentially cause the appendix to rupture, leading to further complications. Therefore, it is best to assess other areas of the abdomen first before palpating the right lower quadrant.
9.
The nurse is preparing to assess a client with flank pain and discomfort and pink-tinged urine. Which of the following assessment techniques would be appropriate for the nurse to use?
Correct Answer
D. Blunt percussion
Explanation
Blunt percussion would be an appropriate assessment technique for the nurse to use in this situation. Flank pain and pink-tinged urine can be indicative of kidney or urinary tract issues. Blunt percussion involves using the fist or a flat object to strike the body surface in order to elicit sounds or vibrations. It is commonly used to assess the kidneys for tenderness or pain. By performing blunt percussion, the nurse can gather information about the client's condition and potentially identify any abnormalities or underlying causes of the symptoms.
10.
During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone. The nurse would document this sound as being:
Correct Answer
C. Tympany
Explanation
The nurse would document the sound as tympany because a loud, high-pitched, drumlike tone is characteristic of this percussion sound. Tympany is typically heard over air-filled structures, such as the stomach or intestines. It is a hollow, musical sound that is produced when air is present in the underlying organs or spaces. This finding is normal and indicates that the client's abdomen is resonating with air, suggesting the absence of any solid or fluid-filled masses.
11.
After auscultating the bowel sounds of a client, the nurse realized the sounds were long. Which of the following would be appropriate for the nurse to use to document this finding?
Correct Answer
C. Duration
Explanation
The nurse would use the term "duration" to document the finding of long bowel sounds. Duration refers to the length of time that a sound lasts. In this case, the nurse observed that the bowel sounds were prolonged or extended in duration.
12.
The nurse is preparing to use a stethoscope while assessing a client. The bell is going to be placed on the client. Which of the following would the nurse assess with the bell of the stethoscope?
Correct Answer
A. Heart murmur
Explanation
The nurse would assess a heart murmur with the bell of the stethoscope. The bell is used to detect low-frequency sounds, such as abnormal heart sounds like murmurs. Lung sounds are typically assessed with the diaphragm of the stethoscope, which is better at detecting high-frequency sounds. Normal heart sounds can also be assessed with the diaphragm, but a heart murmur would require the use of the bell. Abdominal sounds are assessed using a different technique, such as auscultation with the diaphragm or percussion.
13.
The nurse is going to assess a client's blood pressure. To do this, the nurse will need to have:
Correct Answer
D. A stethoscope and a sphygmomanometer
Explanation
To assess a client's blood pressure, the nurse will need a stethoscope and a sphygmomanometer. A stethoscope is used to listen to the sounds of the client's blood flow, while a sphygmomanometer is used to measure the client's blood pressure. The stethoscope helps the nurse to hear the Korotkoff sounds, which indicate the systolic and diastolic blood pressure. The sphygmomanometer is used to inflate and deflate the cuff, allowing the nurse to measure the pressure in the client's arteries. Therefore, having a stethoscope and a sphygmomanometer is essential for accurately assessing a client's blood pressure.
14.
A client complaining of a sore elbow is being assessed by the nurse. Which of the following would help the nurse assess this client?
Correct Answer
B. Goniometer
Explanation
A goniometer is a device used to measure the range of motion of a joint. In the case of a client with a sore elbow, the nurse can use a goniometer to assess the client's elbow flexion and extension. This can help determine the extent of the client's pain and any limitations in movement. The other options, such as skin-fold calipers, penlight, and reflex hammer, are not specifically designed for assessing joint mobility and would not provide relevant information in this scenario.
15.
A client with lower-extremity edema comes into the clinic. During the assessment, the nurse is unable to palpate the client's pedal pulses. Which of the following would be appropriate for the nurse to do?
Correct Answer
D. Use a Doppler to listen to the pulse.
Explanation
The nurse should use a Doppler to listen to the pulse because it is a non-invasive and effective way to assess peripheral pulses in clients with edema. The Doppler uses sound waves to detect blood flow and can help the nurse determine if the client has adequate circulation in the lower extremities. Using a blood pressure cuff or a tourniquet may not provide accurate results and can potentially cause harm to the client.
16.
During a physical assessment, the nurse notices several small scabs along with the inner aspects of both of the client's lower extremities. Which of the following would be appropriate for the nurse to say to this client?
Correct Answer
C. "Can you tell me what caused all of these scabs on your legs?"
Explanation
The nurse should ask the client to explain the cause of the scabs on their legs. This response shows empathy and concern for the client's well-being, allowing them to share any relevant information about their condition. It also avoids making assumptions or jumping to conclusions about the cause of the scabs, such as assuming self-harm or abuse. By asking the client directly, the nurse can gather more information and provide appropriate care and support based on their response.
17.
The nurse is preparing to conduct a physical assessment on a 20-year-old male client with a gaping wound on his right forearm. Which of the following should the nurse do before beginning this examination?
Correct Answer
A. Wash hands
Explanation
Before beginning any examination, it is essential for the nurse to wash their hands. This is a crucial step in infection control and preventing the spread of pathogens. By washing their hands, the nurse can remove any potential contaminants and reduce the risk of introducing harmful bacteria or viruses into the wound or onto the client's skin. Additionally, handwashing promotes patient safety and demonstrates proper hygiene practices, which are essential in healthcare settings.