TTT Exam 1 Chapter 3: Collecting
Objective Data: The Physical
Examination - ML8
✅✅
A client has an enlarged area on the lower leg. Which technique should the nurse
expect to use to assess this body area? - -palpation
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? - -Snellen chart
A client with scabies visits the health care facility for a follow-up appointment. Which
✅✅
preparation by the nurse is of greatest priority for the physical examination of this
client? - -Adequate lighting
A nurse experiences difficulty auscultating the heart sounds of a client. What should
✅✅
the nurse do to enhance the sounds of the heart tones? Select all that apply. -
-Eliminate distracting noises from the environment
Readjust the ear pieces to ensure a snug fit
Angle the binaurals towards the nose
A nurse in the community is completing manual blood pressure assessments at a
✅✅
recreation center. Which action should the nurse take to ensure the assessment is
accurate? - -Turn down the volume if the television or radio is on.
A nurse is examining a client suspected of having a fungal infection of the skin.
✅✅
Which piece of equipment should the nurse use to confirm the presence of fungus? -
-Wood's light
✅✅
A nurse is palpating a child's forehead for signs of fever. Which part of the hand
should the nurse use? - -Dorsal surface
✅✅
A nurse is palpating a client's chest for vibration as he inhales and exhales. Which
part of the hand should the nurse use in this case? - -Palmar surface
A nurse is preparing to conduct an assessment on a client. In what order should the
✅✅
nurse conduct the following actions? Place the steps in the correct order. -
-Wash hands and don gloves.
Take the client's vital signs.
Assess eyes, ears, nose, and mouth.
Auscultate heart and lung sounds.
, Assess genitalia
A nurse is preparing to examine a 45-year-old female client with a family history of
breast cancer. The nurse explains that she will be performing a routine clinical breast
✅✅
examination of the client today. The client objects to having her breasts examined.
How should the nurse respond? - -Explain the importance of the examination
and the risks of breast cancer
✅✅
A nurse is preparing to perform a test for stereognosis in a client. Which piece of
equipment should the nurse use? - -Coin or key
A nurse is preparing to perform auscultation on a client. Which guideline is most
✅✅
important for the nurse to keep in mind while performing this technique? -
-Eliminate distracting noises from the environment.
✅✅
A nurse must assess a client's red reflex. Which piece of equipment will the nurse
need for this? - -Ophthalmoscope
A nurse must examine the rectum of a woman who has complained of bleeding from
✅✅
the anus and pain on defecating. Which of the following positions would be most
appropriate for the client? - -Knee-chest
✅✅
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What
should the nurse do before auscultating? - -
A nurse will be performing a complete physical examination of a man who has
emphysema with a chronic productive cough, including an assessment of his oral
✅✅
cavity. Which pieces of personal protective equipment should the nurse wear? -
-Gloves, mask, protective eye goggles, gown
A nurse, new to the hospital, is attending orientation with the nurse educator. The
✅✅
educator is discussing the use of deep palpation when assessing a client. The nurse
should be aware of what risk when using this assessment technique? - -Risk
for injury
✅✅
A student nurse is performing a head-to-toe assessment on a new client. The nurse
intervenes when which of the following is observed? - -The bell of the
stethoscope is used to auscultate bowel sounds.
During a comprehensive assessment of the lungs of an adult client with a diagnosis
✅✅
of emphysema, the nurse anticipates that during percussion the client will exhibit -
-hyperresonance.
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