Physical Assessment Techniques and | Full Test Bank Ch.7 - Health Assessment in Nursing 4e Test Bank by Cynthia Fenske. DOCX document preview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)
Chapter 7 Physical Assessment Techniques and Equipment
- The nurse is preparing to lightly palpate a client's abdomen. Which part of the hand should the nurse use?
1. Finger pads.
2. Palmer surface of the fingers.
3. Palmer surface of the hand.
4. Finger pads and palmer surface of the fingers.
Page Ref: 84
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment?
1. Using the hyperextended middle finger of the nondominant hand.
2. Using the closed fist of dominant hand.
3. Using the palm of the nondominant hand.
4. Using the fingertips of the dominant hand.
Page Ref: 85
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
- During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate?
1. Document this as abnormal.
2. Avoid moving the stethoscope while listening.
3. Place the diaphragm on top of the client's shirt.
4. Switch from the diaphragm to the bell.
Page Ref: 86
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- The nurse is planning to perform light abdominal palpation on an adult client. Moving the hand slowly in circles, which technique should the nurse use?
1. Using the finger pads, apply a downward pressure of 2 cm.
2. Using the finger pads, apply light pressure at a depth of 1 cm.
3. Using the finger pads, apply a downward pressure of 1/2 cm.
4. Using the finger pads, apply a light pressure of 3 cm.
Page Ref: 84
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
- The nurse is preparing to assess a client's abdomen. Place the sequence for an abdominal assessment is the correct order.
1: Percussion.
2: Palpation.
3: Auscultation.
4: Inspection.
Page Ref: 83
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is inspecting a client's chest and upper extremities. Which would be the appropriate method for the nurse to assess these body areas?
1. Examine the right arm, the chest, and then the left arm.
2. Examine the left arm, the chest, and then the right arm.
3. Examine the left arm, the right arm, and then the chest.
4. Examine the chest and then examine the right and left arms.
Page Ref: 83
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- A client has a reddened area on the left forearm. Which assessment technique should the nurse use to assess this area?
1. Percussion.
2. Light palpation.
3. Moderate palpation.
4. Deep palpation.
Page Ref: 84
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
- While auscultating a client's lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate?
1. Obtain a stethoscope with longer tubing.
2. Ask another nurse to listen to the lung sounds.
3. Hold the stethoscope tubing while listening to the lung sounds.
4. Close the eyes and focus on one sound at a time.
Page Ref: 87
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- The nurse is assessing a client's right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client's skin?
1. Fingertips.
2. Metacarpophalangeal joints.
3. Dorsal surface.
4. Ulnar surface.
Page Ref: 84
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
- The nurse is preparing to percuss the lower lobes of a client's lungs. Which percussion technique is the most appropriate for the nurse to use during this assessment?
1. Direct percussion.
2. Blunt percussion.
3. Indirect percussion.
4. Tapping percussion.
Page Ref: 85
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
- The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? Select all that apply.
1. The stethoscope works by blocking out environmental sounds.
2. Short tubing provides the listener with the most accurate sounds.
3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds.
4. The diaphragm of the stethoscope is used for low pitched sounds.
5. The binaurals should fit snugly in the ears.
Page Ref: 89
Cognitive Level: Understanding
Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- The nurse is preparing to assess a client with an otoscope. Which should the nurse use the otoscope to assess? Select all that apply.
1. Inspecting the nose.
2. Funneling light into the ear canal.
3. Inspecting the internal structures of the eye.
4. Assessing pulses that are not palpable.
5. Detecting fungal infections of the skin.
Page Ref: 91
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is preparing to assess the size and location of an optical lesion. Which light source should the nurse use on the ophthalmoscope?
1. Grid.
2. Slit.
3. Small aperture.
4. Red-free filter.
Page Ref: 90
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The preceptor has reviewed the correct technique to assess heart murmurs with a new nurse. Which statement made by the nurse indicates an understanding?
1. "I will listen for murmurs with the bell of the stethoscope."
2. "A stethoscope with long tubing will produce a better heart sound."
3. "A Doppler is the best instrument to use to listen for murmurs."
4. "The diaphragm of the stethoscope should be used to listen for murmurs."
Page Ref: 89
Cognitive Level: Understanding
Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- The nurse is planning to perform a physical assessment on an adult client. Prior to the assessment, which should be the nurse's first action?
1. Provide a gown for the client to change into.
2. Explain to the client what will happen during the examination.
3. Obtain a written consent.
4. Wash hands in the presence of the client.
Page Ref: 92
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity; Therapeutic Communication
Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is preparing to assess the abdomen of a client experiencing pain. Which technique should the nurse use?
1. Palpating known painful areas first.
2. Touching each area lightly before applying deeper palpation.
3. Performing the exam as quickly as possible.
4. Refraining from conversation during the assessment.
Page Ref: 84
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Basic Care and Comfort
Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
- The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority?
1. Give the client a short break and then resume the assessment.
2. Document what was done and what was refused.
3. Summon another nurse to the room to serve as a witness.
4. Enlist the assistance of the client's family to encourage the rest of the assessment.
Page Ref: 93
Cognitive Level: Analyzing
Client Need & Sub: Safe and Effective Care Environment; Client Rights
Standards: QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination and the patient's power and self-healing processes | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is preparing to perform a complete health assessment on a client. Which actions by the nurse are appropriate just prior to the examination? Select all that apply.
1. Putting on nonsterile gloves.
2. Providing an opportunity for the client to void.
3. Washing hands in the presence of the client.
4. Turning on soft music to relax the client.
5. Ensuring adequate light in the room.
Page Ref: 92
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Basic Care and Comfort
Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment?
1. Resonance.
2. Dullness.
3. Tympany.
4. Hyperresonance.
Page Ref: 86
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
- The nurse is using a Wood's lamp to assess a client's skin. Which should the nurse expect to see if a fungal infection is present?
1. Yellow-green appearance.
2. Reddened appearance.
3. Blue-green appearance.
4. Violet appearance.
Page Ref: 88
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse has completed auscultating the abdomen of a client. Which assessment technique should the nurse expect perform next?
1. Percussion.
2. Palpation.
3. Transillumination.
4. Auscultation.
Page Ref: 83
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
- The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. Which action by the nurse is appropriate in this situation?
1. Check the pressure applied to the probe.
2. Add more gel to the end of the probe.
3. Palpate the pulse then reapply the probe.
4. Replace the probe of the Doppler.
Page Ref: 90
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- A client has a visible pulsation in the middle of his abdomen. Which assessment technique is appropriate for the nurse to use to assess this pulsation?
1. Percussion.
2. Light palpation.
3. Moderate palpation.
4. Deep palpation.
Page Ref: 84
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.
MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
- The nurse is assessing a client with right lower quadrant abdominal pain. Which technique should the nurse use when palpating the abdomen?
1. Assessing the painful area first using moderate palpation.
2. Assessing the painful area last using deep palpation.
3. Assessing the painful area last using light palpation.
4. Assessing the painful area first using deep palpation.
Page Ref: 84
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Basic Care and Comfort
Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
- While percussing a client's lung area the nurse notes a resonance. Which should the nurse recognize the tone indicates?
1. The tone indicates the nurse is percussing over bone.
2. The tone is an expected finding.
3. The tone indicates the lungs contain solid matter.
4. The tone indicates air is trapped in the lungs.
Page Ref: 85
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
- The nurse is unable to palpate a client's pedal pulses. Which item will the nurse use to assess this client's pedal pulses?
1. Stethoscope.
2. Doppler.
3. Transilluminator.
4. Goniometer.
Page Ref: 90
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- The nurse auscultating heart sounds suspects the client has a murmur. Which action should the nurse take?
1. Inform the client of "the abnormality."
2. Stop the assessment and refer the client to the healthcare provider.
3. Request another examiner to assess the finding.
4. Document the finding with a plan to reassess the patient on the next visit.
Page Ref: 92
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VI.2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
- The nurse is preparing to examine several clients in the clinic setting. Which client should the nurse recognize requires special consideration during the physical examination?
1. An adult client with flu symptoms.
2. A preschool-age client in for a well check-up.
3. An adolescent client who complains of fatigue.
4. An older adult client with chronic lung disease.
Page Ref: 93
Cognitive Level: Analyzing
Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
- The nurse is preparing to perform percussion over the lung fields of a client. Which technique should the nurse use to ensure an accurate assessment is obtained?
1. Release the plexor immediately after the first strike.
2. Initiate the motion from the plexor finger.
3. Use the pad of the flexor finger to deliver the blow.
4. Make contact with only the pleximeter.
Page Ref: 86
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.
MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
- The nurse is preparing equipment to be used in an exam. Which principle should the nurse include when preparing the medial equipment?
1. Sterile instruments should be placed on a sterile cloth.
2. All instruments should be placed on a sterile cloth.
3. Clean instruments should be placed on a sterile cloth.
4. A sterile cloth should be placed over the instruments.
Page Ref: 94
Cognitive Level: Applying
Client Need & Sub: Safety and Infection Control; Safe Use of Equipment
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Knowledge and Science: Evidence and best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment
MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.