TEST BANK FOR HEALTH ASSESSMENT
EXAM 1 PHYSICAL EXAMINATION STUDY
GUIDE UPDATED VERSION 100% CORRECT
ANSWERS
A client with an inability to read billboards while driving arrives at the health care facility for an eye
examination. Which piece of equipment should the nurse use to check the client's distant vision? - ANS-
Snellen chart
Explanation:
To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to
view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A
penlight is used to test pupillary constriction.
In which order should a nurse implement the four physical assessment techniques when initiating a
health assessment? - ANS-Inspection, palpation, percussion, auscultation
Explanation:
Inspection is the first physical assessment technique that a nurse should implement. This prevents
altering the appearance of structures that may distract the nurse from completing a focused
observation.
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the
areas the nurse will assess when completing this examination. - ANS-c, d, e, b, a
Explanation:
When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with
the structures closest to the head and progress downward. The nurse will assess the breasts, the chest
and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.
A client is experiencing weakness of the left side of the body. Which piece of equipment should the
nurse use to determine if the client's neurologic system is intact? - ANS-reflex hammer
Explanation:
A reflex is used to assess deep tendon reflexes which are under the control of the neurologic system. A
penlight is used to assess pupillary reflexes and aids with tangential lighting. A scoliometer measures the
degree of spinal curvature. A pulse oximeter measures oxygen level.
.
, What included in personal protective equipment? Select all that apply.
Gloves
Gown
Mouth, nose, eye protection
Special linen
Cleaning processes - ANS-Personal protective equipment (PPE) includes gloves, gown, mouth, nose and
eye protection. Special linen and cleaning processes are not part of PPE.
A female client is reporting burning during urination. The client refuses to allow the nurse to perform a
vaginal assessment. What is the best action of the nurse? - ANS-Explain to the client why the assessment
is important and the possibility of missing important findings.
Explanation:
The nurse should respect the client's request but should also inform her of the risks of not performing
the assessment. The nurse cannot force a client to allow the assessment or deny treatment if the
assessment is not allowed. Telling the client that she can have someone with her during the procedure
may or may not change the client's mind about the assessment.
What is the single most important method of preventing infection transmission by the nurse when
coming into contact with a client? - ANS-Handwashing
Explanation:
Contact transmission from the hands of all health care providers to clients is the most common mode of
transmission, because microorganisms from one client are then spread to others. Wearing latex gloves is
one step in preventing infection transmission but not the most important. Using eye protection and
gowning are important in certain infection transmission situations, but
A client asks why gloves are being worn during the physical examination. What should the nurse
respond to this client? - ANS-They make sure that any microorganisms on my hands do not touch your
skin."
Explanation:
One reason to wear gloves is to prevent the transmission of flora from health care workers to clients.
Wearing gloves is more than just following a policy. Gloves hinder the ability to discern body parts and
positions. Although the client may have a communicable illness, the nurse should not make a statement
that could cause the client anxiety about being ill.
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that
using the bell of the stethoscope is appropriate to auscultate for which type of sounds? - ANS-Heart
murmur
Explanation:
The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or
bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel
sounds.
A nurse needs to position a client in the supine position for the physical examination. The nurse should
ask the client to: - ANS-lie on the back with the legs together on the examining table
Explanation:
The nurse should assist the client to a supine position by instructing him or her to lie down with legs
together on the examining table. To get the client into the dorsal recumbent position, the nurse
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