Collecting Objective Data: Physical Exam Techniques

Question 1

Protect examiner in any part of the
examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items, or when disease-causing agents could be transmitted to or from the client

Answer 1

gloves and gown

Question 2

Measure diastolic and systolic blood pressure;
stethoscope to auscultate blood sounds
when measuring blood pressure

Answer 2

Sphygmomanometer and stethoscope

Question 3

Measure body temperature

Answer 3

Thermometer

Question 4

Take heart rate, pulse rate

Answer 4

Watch with second hand

Question 5

Determine perceived pain level

Answer 5

Pain rating scale

Question 6

Measure skinfold thickness of subcutaneous
tissue

Answer 6

Skinfold calipers

Question 7

Test for fungus

Answer 7

Wood’s light

Question 8

Enlarge visibility of lesion

Answer 8

Magnifying glass

Question 9

Predict one’s risk to develop pressure sore

Answer 9

Braden Scale for predicting pressure sore risk

Question 10

Determine the degree of healing of a pressure injury

Answer 10

pressure injury Scale for
Healing (PUSH)

Question 11

Test for strabismus

Answer 11

Opaque card

Question 12

Test pupillary constriction

Answer 12

Penlight

Question 13

View the red reflex and examine the retina of the eye

Answer 13

Ophthalmoscope

Question 14

Test for bone and air conduction of sound

Answer 14

tuning fork

Question 15

View the ear canal and tympanic membrane

Answer 15

Otoscope

Question 16

Provide light to view the mouth and the throat and to transilluminate the sinuses

Answer 16

Penlight

Question 17

Depress tongue to view throat, check
looseness of teeth, view cheeks, and check strength of tongue

Answer 17

Tongue depressor

Question 18

View the internal nose

Answer 18

Otoscope with wide-tip
attachment

Question 19

Test for vibratory sensation

Answer 19

Tuning fork

Question 20

Test for rise of uvula and gag reflex

Answer 20

Tongue depressor

Question 21

It is important that the nurse strive to ensure that the
examination setting meets the following conditions (6)

Answer 21

• Comfortable, room temperature
• Private area free of interruptions from others
• Quiet area free of distractions
• Adequate lighting
• Firm examination table or bed at a height that prevents stooping
• A bedside table/tray to hold the equipment needed for the examination

Question 22

means cleaning your hands by using handwashing (washing hands
with soap and water), antiseptic handwash, antiseptic hand rub (i.e., alcohol-based
hand sanitizer including foam or gel), or surgical hand antisepsis.

Answer 22

Hand hygiene

Question 23

are the most effective products for reducing the number of germs on the hands of health care providers.

Answer 23

Alcohol-based hand sanitizers

Question 24

are the preferred method for cleaning your hands in most clinical situations.

Answer 24

Alcohol-based hand sanitizers

Question 25

Wash your hands with ??? whenever they are visibly dirty, before eating, and after using the restroom.

Answer 25

soap and water

Question 26

Establish the ??? during the client interview before the physical examination takes place.

Answer 26

nurse–client relationship

Question 27

This position is good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is also useful because it permits full expansion of the lungs and it allows the examiner to assess symmetry of upper body parts.

Answer 27

sitting

Question 28

This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities.

Answer 28

supine

Question 29

This position may be more comfortable than the supine position for clients with pain in the back or the abdomen. Areas that may be assessed with the client in this position include head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The abdomen should not be assessed because the abdominal muscles are contracted in this position.

Answer 29

dorsal recumbent

Question 30

This position is useful for assessing the rectal and vaginal areas. The client may need some assistance getting into this position. Clients with joint problems and elderly clients may have some difficulty assuming and maintaining this position.

Answer 30

sims

Question 31

This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia.

Answer 31

standing

Question 32

used primarily to assess the hip joint. The back can also be assessed with the client in this position. Clients with cardiac and respiratory problems cannot tolerate this position.

Answer 32

prone

Question 33

useful for examining the rectum. This position may be embarrassing and uncomfortable for the client; therefore, the client should be kept in the position for as limited a time as possible.

Answer 33

knee-chest position

Question 34

s used to examine the female genitalia, reproductive tracts, and the rectum. The client may require assistance getting into this position. It is an exposed position, and clients may feel embarrassed. In addition, elderly clients may not be able to assume this position for very long or at all. Therefore, it is best to keep the client well draped during the examination and to perform the examination as quickly as possible.

Answer 34

lithotomy

Question 35

Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are ?

Answer 35

inspection, palpation, percussion, and auscultation.

Question 36

involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.

Answer 36

Inspection

Question 37

consists of using parts of the hand to touch and feel for some characteristics

Answer 37

Palpation

Question 38

Three different parts of the hand are used during palpation

Answer 38

the fingerpads, ulnar/palmar surface, and dorsal surface

Question 39

hand part: Fine discriminations: pulses, texture, size, consistency, shape, crepitus

Answer 39

Fingerpads

Question 40

hand part: Vibrations, thrills, fremitus

Answer 40

Ulnar or palmar surface

Question 41

hand part: Temperature

Answer 41

Dorsal (back) surface

Question 42

the four types of palpation

Answer 42

light moderate deep bimanual

Question 43

palpation: To perform ? palpation (Fig. 3-1), place your dominant hand lightly on the surface of the structure. There should be very little or no depression (<1 cm). Feel the surface structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture.

Answer 43

light

Question 44

palpation: Depress the skin surface 1 to 2 cm (0.5–0.75 in.) with your dominant hand, and use a circular motion to feel for easily palpable body organs and masses. Note the size, consistency, and mobility of structures you palpate.

Answer 44

moderate

Question 45

palpation: Place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure (Fig. 3-2). This should result in a surface depression between 2.5 and 5 cm (1 and 2 in.). This allows you to feel very deep organs or structures that are covered by thick muscle.

Answer 45

deep

Question 46

palpation: Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated (Fig. 3-3). Use one hand to apply pressure and the other hand to feel the structure. Note the size, shape, consistency, and mobility of the structures you palpate

Answer 46

Bimanual

Question 47

involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.

Answer 47

Percussion

Question 48

The three types of percussion are

Answer 48

direct, blunt, and indirect

Question 49

is the direct tapping of a body part with one or two fingertips to elicit possible tenderness (e.g., tenderness over the sinuses).

Answer 49

Direct percussion

Question 50

is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.

Answer 50

Blunt percussion

Question 51

is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures.

Answer 51

Indirect or mediate percussion

Question 52

As density increases, the sound of the tone becomes ???

Answer 52

quieter

Question 53

??? produces a soft tone, ??? produces a louder tone, and ??? produces an even louder tone.

Answer 53

Solid tissue fluid air

Question 54

is a type of assessment technique that requires the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract.

Answer 54

Auscultation

Question 55

Use the ??? of the stethoscope to listen for low-pitched sounds such as abnormal heart sounds and bruits

Answer 55

bell

Question 56

Use the ??? of the stethoscope to listen for high-pitched sounds, such as normal heart sounds, breath sounds, and bowel sounds, and press the diaphragm firmly on the body part being auscultated.

Answer 56

diaphragm