Funds Ch 21 Physical Assessment

The nurse uses the five techniques for obtaining objective data when performing the physical assessment of a client. Which technique provides assessment information through the use of the nurse’s hands?

• Palpation

• Auscultation

• Observation

• Olfaction

The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?

• Biot

• Cheyne–Stoke

• Bradypnea

• Kussmaul

The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What would the nurse expect to hear when auscultating the lungs of this client?

• Stridor

• Friction Rub

• Sibilant wheeze

• Decreased breath sounds

A nurse is gathering information about a patient’s which include demographic data, chief complaint, history of current illness, allergies, medications, adverse reactions to medications, medical history, family and social history, and health promotion practices habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?

• Carefully review lab results.
• Conduct the physical assessment.
• Perform a thorough in-depth health history.
• Prolong the termination phase of the interview.

The nurse is preparing to assess a client’s abdomen. Which of the following sequences will the nurse use to assess this body area?

• Percussion, Palpation, Auscultation, Inspection

• Auscultation, Inspection, Palpation, Percussion

• Inspection, Palpation, Percussion, Auscultation

• Inspection, Auscultation, Percussion, Palpation

The nurse is assessing a client’s right lower extremity and during inspection notes an area of redness. In order to assess the temperature of the client’s skin, the nurse should use which part of the hand?

• Fingertips

• Metacarpophalgeal joints

• Dorsal surface

• Ulnar surface

The nurse is about to perform a physical assessment on an adult client. Before beginning this phase of the client’s health assessment, the nurse should first:

• Provide a gown for the client to change into.

• Explain to the client what will happen during the examination.

• Obtain a written consent.

• Wash hands in the presence of the client.

While percussing a client’s lung area the nurse notes a flat tone. This tone would indicate:

• The nurse is percussing over a bone.

• A normal finding.

• The lungs are solidified.

• Air is trapped in the lungs.

The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity as a way to obtain data related to which of the following?

• The client’s mobility status

• Subjective assessments related to ambulation

• Activity tolerance

• Strength of upper and lower extremities

The nurse is conducting an abdominal assessment. Which of the following assessment findings requires further assessment?

• 20 gurgles per minute in each quadrant

• Client stating that they have 1 bowel movement per day

• Active bowel present

• Absent bowel sounds