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Terms in this set (15)
A nurse is preparing to perform a full cardiac and pulmonary exam on a patient. What patient position is appropriate for the nurse to complete this exam?
Supine
Fowlers
Prone
Dorsal Recumbent
What statement by the patient about hand-washing indicates the patient is in further need of education?
"Washing my hands with antibacterial soap means they are sterile."
Washing hands with antibacterial soap means they are bacteria free, but it does not mean they are sterile.
Which factors should a nurse consider before performing an inspection during a physical exam?
Ample Lighting
Time available for exam
adequate exposure of anatomical features
available assistance
What kind of abnormalities can be found with percussion of the abdomen?
Gas
Fluid
Masses
Rebound Tenderness
A patient has fallen and suffered a leg injury. A nurse is palpating the leg during the initial examination. The nurse should be attentive to what qualities or reaction?
Crepitation
Guarding
Rebound Tenderness
A nurse is examining a patient who is complaining of stomach pain. After auscultation of the abdomen, the nurse documents the sounds according to what criteria?
Frequency
Intensity
Crepitation
Which factors should a nurse consider when documenting findings after performing a physical assessment?
Highlight any abnormalities or questionable findings.
Review for accuracy and attention to detail.
Record education given to the patient or family.
Record the assessment in a timely manner.
What should a nurse do when an adult with severe developmental disabilities presents to the hospital and has to wait for the healthcare provider?
Have the nurse assistant sit with the patient until the provider arrives.
Adults with severe developmental disabilities may not be safe in a room by himself or herself, so having a nurse assistant sit with the patient protects the patient from harm while waiting for the health care provider's arrival.
A nurse is teaching a class about patient privacy and HIPAA requirements to new staff in a medical clinic. Which statement demonstrates that the content is understood?
Make sure to keep medical charts behind the desk and out of the view of other patients at all times.
All medical charts should be kept behind the desk or away from other patient's view at all times.
The nurse has completed the physical examination on a patient. After the patient has changed clothing, the nurse's next step is to:
Allow the patient to ask questions.
Patients should be given a chance to ask questions or add any additional information that may have been forgotten earlier.
What is the order of assessment techniques when assessing the abdomen?
Inspection
Palpation
Percussion
Auscultation
The nurse is performing a physical assessment on a patient. During inspection, it is imperative that the nurse have _________________and _________ available
Good lighting and gloves
Good lighting is essential to the quality of this part of the exam, as is having enough time to adequately complete it. The nurse should wear gloves during the inspection phase of the physical examination.
The process of inspection utilizes which senses in order to identify normal and abnormal physical characteristics?
Sight
Smell
A nurse is assessing a patient with complaints of dizziness, palpitations, and fainting. The patient had been outside in the heat all day and is likely suffering from dehydration. What factor should the nurse make sure to assess when performing palpation?
Skin turgor
A patient who is complaining of fainting, dizziness, and palpitations after spending a significant amount of time outside should be assessed for dehydration. Delayed skin turgor or tenting is a sign of dehydration.
The nurse must examine an older adult patient with arthritis and dementia. What actions are required for a safe and effective examination for this patient?
Assisting the patient with undressing
Helping the patient change position
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