Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico – Test Bank

Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico – Test Bank

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Chapter 9

Question 1 Type: HOTSPOT The nurse educator is demonstrating the proper technique for assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate proper technique? 1. A. 2. B. 3. C. 4. D. Correct Answer: 3 Rationale 1: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand. Rationale 2: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand. Rationale 3: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand. Rationale 4: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand. Global Rationale: Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 146 Question 2 Type: MCSA 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. Correct Answer: 4 Rationale 1: Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Rationale 2: Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. Rationale 3: The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion. Rationale 4: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult client. Global Rationale: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an adult client. Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 147 Question 3 Type: MCSA 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. Wet the chest hair before auscultating the chest. 3. Place the diaphragm on top of the client’s shirt. 4. Switch from the diaphragm to the bell. Correct Answer: 2 Rationale 1: The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Rationale 2: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation. Rationale 3: Auscultating lung sounds over the client’s clothing will increase rather than decrease friction sounds. Rationale 4: Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference. Global Rationale: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation. The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Auscultation of lung sounds over the client’s clothing will increase rather than decrease friction sounds. Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 148–149 Question 4 Type: MCSA The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment? 1. Downward pressure of 1–2 cm using the finger pads. 2. Side to side pressure of ½–1 cm using the finger pads. 3. Downward pressure of 2–4 cm using the palmar surface of the fingers 4. Light pressure using the base of the fingers (metacarpophalangeal joints). Correct Answer: 2 Rationale 1: Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Rationale 2: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Rationale 3: Deep palpation of 2–4 cm (3/4–1½ in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Rationale 4: Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus. Global Rationale: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Deep palpation of 2–4 cm (3/4–1½ in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 145–147 Question 5 Type: SEQ The nurse is preparing to assess a client’s abdomen. Place the sequence for an abdominal assessment is the correct order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Percussion. Response 2. Palpation. Response 3. Auscultation. Response 4. Inspection. Correct Answer: 4, 3, 1, 2 Rationale 1: Percussion is the third step taken during an abdominal assessment. Rationale 2: Palpation is the last step taken during an abdominal assessment. Rationale 3: Auscultation is the second step taken during an abdominal assessment. Rationale 4: Inspection is the first step taken during an abdominal assessment. Global Rationale: The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen. Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation, then percussion, and finally palpation. Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 145 Question 6 Type: MCSA 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 arms at the conclusion of the exam, as the client is re-dressing. Correct Answer: 3 Rationale 1: The nurse should compare the left and right arms before moving to the chest. Rationale 2: The nurse should compare the left and right arms before moving to the chest. Rationale 3: Inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. Rationale 4: The nurse should give the client privacy at the conclusion of the physical assessment to re-dress. Global Rationale: Inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. The nurse should give the client privacy at the conclusion of the physical assessment to re-dress. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 145 Question 7 Type: MCSA 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. Correct Answer: 2 Rationale 1: Percussion is used to determine the size and shape of organs and masses, and whether underlying tissue is solid or filled with air or fluid. Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Rationale 3: Moderate palpation is used to assess most of the other structures of the body. Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity. Global Rationale: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Percussion is used to determine the size and shape of organs and masses, and whether underlying tissue is solid or filled with air or fluid. Moderate palpation is used to assess most of the other structures of the body. Deep palpation is used to assess an organ that lies deep within a body cavity. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 146 Question 8 Type: MCSA 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. Correct Answer: 4 Rationale 1: Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Rationale 2: Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Rationale 3: Touching the stethoscope tubing can cause additional sounds and should be avoided. Rationale 4: Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Global Rationale: Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Touching the stethoscope tubing can cause additional sounds and should be avoided. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 149 Question 9 Type: MCSA 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. Metacarpophalgeal joints. 3. Dorsal surface. 4. Ulnar surface. Correct Answer: 3 Rationale 1: The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. Rationale 2: The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. Rationale 3: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. Rationale 4: The ulnar surface of the hand is also used to assess for fremitus. Global Rationale: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. The ulnar surface of the hand is also used to assess for fremitus. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 146 Question 10 Type: MCSA 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. Any of the percussion techniques. Correct Answer: 3 Rationale 1: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult. Rationale 2: Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow. Rationale 3: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. Rationale 4: In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion. Global Rationale: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult. Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow. This method is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 147–148 Question 11 Type: MCMA 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? Standard Text: 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. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection. 5. The binaurals should fit snugly in the ears. Correct Answer: 1, 2, 5 Rationale 1: The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. Rationale 2: Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. Rationale 3: The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. Rationale 4: The stethoscope should be cleaned after examining a client to prevent the spread of infection. Rationale 5: The binaurals should fit snugly yet comfortably in the ears. Global Rationale: The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. The binaurals should fit snugly yet comfortably in the ears. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. The stethoscope should be cleaned after examining a client to prevent the spread of infection. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 148; 151 Question 12 Type: MCMA When is it appropriate for the nurse to use an otoscope during a physical assessment? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: The otoscope can be used to inspect the nose, by inserting a wide speculum into the client’s naris. Rationale 2: The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. Rationale 3: The ophthalmoscope is used to inspect the internal structure of the eye. Rationale 4: The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. Rationale 5: A Wood’s lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection. Global Rationale: The otoscope can be used to inspect the nose, by inserting a wide speculum into the client’s naris. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. The ophthalmoscope is used to inspect the internal structure of the eye. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. A Wood’s lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 152–153 Question 13 Type: MCSA The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which color is visualized through the red-free filter of the ophthalmoscope? 1. Green. 2. Black. 3. Red. 4. Yellow. Correct Answer: 2 Rationale 1: The color green is not an expected finding of fundoscopic examination of the eye. Rationale 2: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black. Rationale 3: The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding. Rationale 4: Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope. Global Rationale: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black. The color green is not an expected finding of fundoscopic examination of the eye. The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding. Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope. Cognitive Level: Remembering Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 152 Question 14 Type: HOTSPOT The nurse educator is teaching a group of nursing students the correct assessment of heart murmurs. Which part of the stethoscope will the educator press against the client’s chest during this assessment? 1. A. 2. B. 3. C. 4. D. Correct Answer: 2 Rationale 1: The diaphragm of the stethoscope is used to assess normal heart sounds. Rationale 2: The bell of the stethoscope is used to assess murmurs. Rationale 3: The earpieces fit into both ears to allow the nurse to hear sounds when auscultating. The earpieces are not placed against the client’s chest during auscultation. Rationale 4: The tubing length can distort sound; however, this is not placed against the client’s chest during auscultation. Global Rationale: The bell of the stethoscope is used to assess murmurs. The diaphragm of the stethoscope is used to assess normal heart sounds. The earpieces fit into both ears to allow the nurse to hear sounds when auscultating. The earpieces are not placed against the client’s chest during auscultation. The tubing length can distort sound; however, this is not placed against the client’s chest during auscultation. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 151 Question 15 Type: MCSA The nurse is planning to perform a physical assessment on an adult client. Before beginning this phase of the client’s health assessment, which action by the nurse is the most appropriate? 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. Correct Answer: 2 Rationale 1: The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing. Rationale 2: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client’s anxiety and enlists the client’s cooperation with the assessment. Rationale 3: Obtaining a written consent is not necessary, unless an invasive procedure will be performed. Rationale 4: Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given and again at the completion of the physical assessment. Global Rationale: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client’s anxiety and enlists the client’s cooperation with the assessment. The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing. Obtaining a written consent is not necessary, unless an invasive procedure will be performed. Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 154 Question 16 Type: MCSA The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. Which technique is appropriate for the nurse to use when assessing this client’s abdomen? 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. Correct Answer: 2 Rationale 1: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. Rationale 2: Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. Rationale 3: Rushing through the exam will not help with the client’s anxiety. Rationale 4: The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client’s health. Global Rationale: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. The nurse should proceed slowly, using smooth, deliberate movements during the exam. The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client’s health. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 145–147 Question 17 Type: MCSA 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. Correct Answer: 2 Rationale 1: The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. Rationale 2: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. Rationale 3: It is not necessary for another nurse to witness a client’s refusal of care. The nurse should document what was done and what the client refused. Rationale 4: Allowing a family member to be present during the assessment may be helpful, but the client’s wishes (refusal) must be respected. Global Rationale: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. It is not necessary for another nurse to witness a client’s refusal of care. The nurse should document what was done and what the client refused. Allowing a family member to be present during the assessment may be helpful, but the client’s wishes (refusal) must be respected. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 154 Question 18 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 3, 5 Rationale 1: Gloves are needed only if the nurse may come into contact with the client’s blood or body fluids, such as during the assessment of the genitalia or anus. Rationale 2: The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. Rationale 3: The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client’s safety and also protects the nurse. Rationale 4: The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. Rationale 5: The room should be brightly lit to facilitate good visibility. Global Rationale: The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client’s safety and also protects the nurse. Gloves are needed only if the nurse may come into contact with the client’s blood or body fluids, such as during the assessment of the genitalia or anus. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. The room should be brightly lit to facilitate good visibility. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.3: Demonstrate patient safety and comfort measures that should be implemented when performing a physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 153–154 Question 19 Type: MCSA The nurse is assessing a client’s abdomen. Which sound is expected when percussion is used during the assessment? 1. Loud, low-pitched. 2. Soft, high-pitched. 3. Drum-like. 4. Abnormally loud. Correct Answer: 3 Rationale 1: Resonance is a loud, low-pitched tone of normal findings over the lungs. Rationale 2: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Rationale 3: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Rationale 4: Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs. Global Rationale: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Resonance is a loud, low-pitched tone of normal findings over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs. Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 148 Question 20 Type: MCSA A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more detailed neurological assessment of this client? 1. Asymmetry of the client’s smile. 2. Grimacing with movement. 3. Talking in a loud voice. 4. Inability to follow directions. Correct Answer: 1 Rationale 1: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Rationale 2: Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Rationale 3: Talking in a loud voice may cue the nurse that the client has hearing loss. Rationale 4: The client’s inability to follow directions may also be the result of a hearing loss. Global Rationale: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Talking in a loud voice may cue the nurse that the client has hearing loss. The client’s inability to follow directions may also be the result of a hearing loss. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 153–155 Question 21 Type: MCSA The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment? 1. Percussion. 2. Palpation. 3. Transillumination. 4. Auscultation. Correct Answer: 1 Rationale 1: After auscultating the client’s abdomen, the nurse would begin percussion. Rationale 2: Palpation is the last step of the abdominal assessment. Rationale 3: Transillumination of the abdomen is not part of the abdominal assessment. Rationale 4: Auscultation is the second step of the abdominal assessment. Global Rationale: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Percussion and palpation could alter the natural sounds of the abdomen; therefore, it is important to auscultate before performing palpation and percussion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 145 Question 22 Type: MCSA 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. Checking the pressure applied to the probe. 2. Adding more gel to the end of the probe. 3. Informing the healthcare provider immediately. 4. Sending the equipment for repair. Correct Answer: 1 Rationale 1: Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client’s skin, over the artery to be auscultated. Rationale 2: A small amount of gel is applied to the end of the Doppler probe to eliminate interference. Rationale 3: Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly. Rationale 4: Sending the equipment for repair is premature at this time. Global Rationale: Heavy pressure to the probe should be avoided because it may impede blood flow—the probe should be placed gently against the client’s skin, over the artery to be auscultated. A small amount of gel is applied to the end of the Doppler probe to eliminate interference. Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly. Sending the equipment for repair is premature at this time. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 151–152 Question 23 Type: MCSA 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. Correct Answer: 3 Rationale 1: Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Rationale 3: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present. Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity. Global Rationale: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Deep palpation is used to assess an organ that lies deep within a body cavity. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 146 Question 24 Type: MCSA The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which action by the nurse is appropriate when palpating this client’s 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. Correct Answer: 2 Rationale 1: Painful areas are not palpated first. Rationale 2: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. Rationale 3: Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. Rationale 4: While deep palpation is the appropriate technique, the painful area is examined last. Global Rationale: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. Painful areas are not palpated first. Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. While deep palpation is the appropriate technique, the painful area is examined last. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 145–147 Question 25 Type: MCSA While percussing a client’s lung area the nurse notes a resonance. What does the tone indicate? 1. The nurse is percussing over a bone. 2. A normal finding. 3. The lungs are solidified. 4. Air is trapped in the lungs. Correct Answer: 2 Rationale 1: Flat tones are high-pitched, soft tones of short duration and are the result of percussion over solid tissue such as muscle or bone. Rationale 2: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. Rationale 3: Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration. Rationale 4: Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance. Global Rationale: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. Flat tones are high-pitched, soft tones of short duration are the result of percussion over solid tissue such as muscle or bone. Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration. Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 148 Question 26 Type: MCSA 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. Correct Answer: 2 Rationale 1: A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. Rationale 2: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. Rationale 3: A transilluminator detects blood, fluid, or masses in body cavities. Rationale 4: A Goniometer is used to measure the degree of joint flexion and extension. Global Rationale: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. A transilluminator detects blood, fluid, or masses in body cavities. A goniometer is used to measure the degree of joint flexion and extension. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 151–152 Question 27 Type: MCSA While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate? 1. Informing the client of “the abnormality.” 2. Stopping the assessment and referring the client to the healthcare provider immediately. 3. Bring in another examiner to assess the finding. 4. Documenting the finding and reassessing at the client’s next visit. Correct Answer: 3 Rationale 1: Informing the client of “the abnormality” may cause the client undue anxiety, as the finding may be a normal variant. Rationale 2: When the nurse identifies an unfamiliar finding, it is appropriate complete the assessment before referral to a healthcare provider. Rationale 3: The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse’s unfamiliar finding. Rationale 4: The finding should be investigated at this visit, first by asking another examiner to assess the concern. Global Rationale: The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse’s unfamiliar finding. The finding should be investigated at this visit, first by asking another examiner to assess the concern. When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Informing the client of “the abnormality” may cause the client undue anxiety, as the finding may be a normal variant. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: pp. 153–155 Question 28 Type: MCSA The nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a 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. Correct Answer: 4 Rationale 1: A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease. Rationale 2: Assessment approaches and techniques may vary for children, but a 3-year-old is not considered at the same risk potential as a client with a chronic respiratory illness. Rationale 3: Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general, the position changes required during the complete health assessment should not be taxing on a teen. Rationale 4: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. Global Rationale: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease. Assessment approaches and techniques may vary for children, but a 3-year-old is not considered at the same risk potential as a client with a chronic respiratory illness. Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: 9.4: Apply critical thinking when using the four basic techniques of physical assessment. MNL Learning Outcome: 2.2. Techniques of Physical Assessment Page Number: p. 154 Question 29 Type: MCMA The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which should the nurse incorporate into the physical assessment of this client? Standard Text: Select all that apply. 1. Washing hands in the presence of the client. 2. Putting on nonsterile gloves to examine the client. 3. Ensuring that the client has an empty bladder before beginning the physical assessment. 4. Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. 5. Assessing only the left lower extremity since this is the injured body part. Correct Answer: 1, 2 Rationale 1: The nurse should always perform handwashing prior to physical contact with a client. Rationale 2: Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens. Rationale 3: When the client’s abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. Rationale 4: The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client’s anxiety. Rationale 5: The nurse should always do a comparison of both sides of the body. Global Rationale: The nurse should always perform handwashing prior to physical contact with a client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens. When the client’s abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client’s anxiety. The nurse should always do a comparison of both sides of the body. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. NLN Competencies: Quality and Safety: Factors that contribute to a system-wide safety culture; The importance of reporting hazards and adverse events; The “just culture” approach to system improvement. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5: Apply the principles of Standard Precautions in practice. MNL Learning Outcome: 1.1.1. Identify factors that affect safety across the life span. Page Number: p. 155 Question 30 Type: MCMA The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child? Standard Text: Select all that apply. 1. Putting on nonsterile gloves prior to assessing the child’s injuries. 2. Disposing of blood-soaked gauze in the office trash bin. 3. Performing handwashing before touching the child. 4. Asking the child permission to assess the injuries. 5. Wearing a mask while washing the child’s abrasions. Correct Answer: 1, 3, 4 Rationale 1: The use of nonsterile gloves protects the student nurse from direct contact with the child’s blood. Rationale 2: The school nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin. Rationale 3: Handwashing should be performed before and after client care. Rationale 4: Asking permission to assess the child’s injuries gains the child’s attention and cooperation. Rationale 5: Wearing a mask is not necessary when washing the child’s abrasions. Global Rationale: The student nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin. The use of nonsterile gloves protects the student nurse from direct contact with the child’s blood. Handwashing should be performed before and after client care. Asking permission to assess the child’s injuries gains the child’s attention and cooperation. Wearing a mask is not necessary when washing the child’s abrasions. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. NLN Competencies: Quality and Safety: Factors that contribute to a system-wide safety culture; The importance of reporting hazards and adverse events; The “just culture” approach to system improvement. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5: Apply the principles of Standard Precautions in practice. MNL Learning Outcome: 1.1.1. Identify factors that affect safety across the life span. Page Number: p. 155