Exam 1 Flashcards
During auscultation of the patient’s chest, how should the nurse position the stethoscope to minimize extraneous noises?
Position the head of the stethoscope between the second and third fingers and position it on the patient’s skin
When using a stethoscope during the physical exam, how should the stethoscope be positioned in the nurse’s ears to optimize hearing and comfort?
The earpieces should fit snugly in the ear canals
The earpieces should be angled toward the nose
When auscultating the patient’s lungs, how should the head of the stethoscope be held?
The diaphragm held firmly on the posterior lung fields
What action by the nurse is most appropriate to ensure an accurate pulse oximetry reading for a patient wearing fingernail polish?
Remove all the nail polish from the finger before placing the sensor probe
Which patient would the nurse anticipate having an inaccurate pulse oximetry reading?
An agitated patient thrashing in the bed
A patient with a sensor probe placed over nail polish
A patient with a sensor probe placed over the tip of the nose
When obtaining the pulse oximetry reading, what action will help verify the accuracy of the measurement?
Ensuring that the photodetectors in the probe are aligned before placing the sensor probe on the patient
If a nurse needs to repeat a blood pressure measurement, what is the most appropriate action to avoid a falsely high result?
Support the arm at heart level and wait at least 1 minute before repeating the blood pressure measurement
What action should the nurse take if the blood pressure obtained using an automatic cuff is significantly higher than the patient’s baseline?
Measure the blood pressure in the opposite arm and compare readings
Which actions help to prevent false blood pressure readings?
Select the correct cuff size for the limb being used
Support the arm at heart level during blood pressure measurement
What is the purpose of using the aperture and lenses of the ophthalmoscope?
To control focus during the eye examination
To compensate for myopia or hyperopia in the nurse or patient
To allow for light variations during the eye examination
To examine the retina for hemorrhage or lesions
Which ophthalmoscope setting should the nurse select to increase magnification and produce a larger field of view?
Select the positive numbers in the lens indicator
How should the nurse insert the otoscope speculum to best inspect the auditory canal and prevent injury in an adult patient?
Tilt the patient’s head slightly toward the opposite ear before inserting the otoscope speculum
What is the correct description of the use of the otoscope to examine the inside of the nose?
An otoscope using the shortest, widest speculum can be used to examine the nares of the nose.
What actions demonstrate proper positioning of the otoscope for assessment of a patient’s inner ear?
Holding the otoscope with the handle end in the upward position
Holding the otoscope against the patient’s head
Inserting the speculum into the patient’s ear
What statement demonstrates an understanding of the proper use of the percussion (reflex) hammer?
The percussion hammer should move in a swift arc and in a controlled direction during use.
What action is most appropriate to ensure the nurse achieves a full swinging motion while using a reflex hammer?
Hold the handle of the hammer loosely between thumb and index finger when swinging the hammer
How should the nurse position the patient to assess deep tendon reflexes?
Position the patient’s extremity so the tendon is slightly stretched
Manipulate the patient’s joint being tested away from you
When assessing vision of a small child, what visual acuity charts are appropriate?
Tumbling E
HOTV
LH symbols
What action best demonstrates proper use of the pocket visual acuity card when assessing patient’s near vision?
The patient holds the Rosenbaum chart 14 inches from the face.
What does a visual acuity measurement of 20/40 +2 mean?
The patient can read all the letters in the 20/40 line plus two letters in the 20/30 line correctly.
When assessing vibratory sensation, what action by the nurse is appropriate to activate the tuning fork?
Hold the tuning fork by the stem and tap the prongs against the heel of the hand
For which type of patient would the nurse use the tuning fork to further assess function?
Patient with loss of hearing
What should the nurse do if the patient is unable to feel the vibration of the tuning fork during assessment?
Move the tuning fork proximally until the vibratory sensation is felt
Order the steps to prepare the ophthalmoscope for use in an eye examination.
Seat the ophthalmoscope in the handle
Push downward
Turn the head in a clockwise direction
Lock the two pieces into place
Depress the on/off switch
Turn the rheostat control clockwise to desired light intensity
To ensure accurate findings, what information would the nurse verify prior to beginning inspection?
Overhead lighting and a lamp are available.
Which condition is necessary for accurate inspection?
Adequate time to complete exam
Which part of the hand is used to palpate the patient’s abdomen?
Finger pads
Which part of the hand would the nurse use to palpate pulsations?
Finger pads
During an abdominal assessment, palpation occurs after auscultation for what reason?
Palpation may increase intestinal activity.
Which tone would the nurse expect to hear when percussing over the stomach?
Tympany
Which tone would the nurse expect to hear when percussing over the lungs?
Resonance
Which tone would the nurse expect to hear when percussing over bone?
Flatness
What percussion tone would indicate air-filled (emphysematous) lungs?
Hyperresonance
Which techniques are required to conduct accurate percussion?
Downward snap the striking finger
Tap sharply and rapidly
Use the tip of the finger to strike
Have short fingernails
Which auscultation techniques are correct for auscultating the heart and lungs?
Isolate each sound and listen to it separately
Focus on the characteristics of each sound
Match the auscultation guidelines with correct rationale.
Have a quiet environment
P
revents distraction
Auscultate directly on skin
Avoids obscured sounds
Take time for auscultation
Important to identify characteristics
Listen to one sound at a time
Distinguishes between two sounds
What guidelines should the nurse follow to ensure that auscultation sounds are accurately heard?
Ensure that the stethoscope endpiece is firmly held against the skin
What components are included in a general inspection of the patient?
Overall color of skin
Symmetry of body
Obvious injuries
Which part of the hand is best used to assess for fremitus, or vibrations?
Ball of hand
Place the steps for indirect percussion technique in order.
Expose patient’s skin by removing gown as needed.
Place middle finger of nondominant hand firmly on patient’s skin.
Keep the remaining fingers of the nondominant hand fanned out and off the surface of the skin.
Snap the wrist of the dominant hand downward.
With dominant hand, strike the middle finger of nondominant hand.
At which developmental age do the legs grow faster than any other body part?
Child
What physical assessment findings in the older adult suggest skeletal muscle loss?
Increased fat
Loss of body weight
Which statement is correct concerning fetal growth and development?
Head growth predominates.
Which organ completes physical development more quickly than other body parts?
Brain
Which statement about infant brain development is true?
Disruption of brain development during infancy can affect brain function.
At what age does the head make up nearly 50% of the body?
2-month-old fetus
Which hormone helps regulate an individual’s height?
nsulin-like growth factor-1
Which hormone, regulated by insulin, stimulates cells that control connective tissue growth and ossification?
Insulin-like growth factor-1
Which hormone may influence appetite and food intake?
Ghrelin
Growth hormone–releasing hormone stimulates the pituitary gland to release which hormone?
Growth hormone
When a parent asks about a child’s bone growth, the nurse explains that which hormone is responsible for bone maturation and epiphyseal fusion?
Testosterone
Which hormones, secreted by the gonads, are responsible for maturation of genitalia during puberty?
Testosterone
Estrogen
Establishing a good rapport with the patient facilitates the nurse’s ability to obtain which information?
Details about a patient’s complaint
The patient’s expectations
Asking several consecutive yes/no questions should be avoided for which reason?
They may confuse the patient.
They discourage the patient from providing additional information.
A necessary part of establishing a good rapport with a patient is to understand the patient’s perspective on the condition and treatment plan. How does this help the history-taking process?
Prevents miscommunication and misinterpretations
Why is it important for the nurse to establish a good rapport by ensuring each patient-nurse interaction is unique?
To build trust
While preparing the patient room before beginning an interview, which steps should the nurse take to ensure patient comfort and establish good patient-nurse rapport?
Drawing the curtains
Adjusting the room temperature
Addressing immediate patient needs
Asking others to leave the room
Which steps should the nurse take to establish and maintain a good rapport with the patient?
Ensure patient comfort
Use effective communication
Use appropriate body language
Focus on the patient
Which appropriate actions taken by the nurse demonstrate that body language is important in establishing and maintaining a good rapport with the patient?
Sitting during the interview
Keeping an appropriate distance
Effective communication relies on the nurse implementing which communication techniques?
Courtesy
Comfort
Connection
Confidentiality
