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A nurse is introducing herself to a client as the first step of a comprehensive physical
examination. Which of the following strategies should the nurse use with this client? (select all
that apply)
A. Address the client with the appropriate title and her last name.
B. Use a mix of open- and close-ended questions.
C. Reduce environmental noise.
D. Have the client complete a health history form.
E. Perform the general survey before the examination.
Correct Answer: B, C, E
Rationale:
B. Open‑ended questions help the client tell her story in her own way. Closed‑ended questions
are useful for clarifying and verifying information the nurse gathers from the client's story
C. quiet, comfortable environment eliminates distractions and helps the client focus on the
important aspects of the interview.
E. The general survey is noninvasive and, along with the health history and vital sign
measurement, can help put the client at ease before the more sensitive parts of the process,
such as the examination
A nurse in a provider's office is documenting his findings following an examination he
performed for a client new to the practice. Which of the following parameters should he include
as part of the general survey? (Select all that apply.)
A. Posture
,B. Skin lesions
C. Speech
D. Allergies.
E. immunization status
Correct Answer: A, B, C
Rationale:
A. Posture is part of the body structure or general appearance portion of the general survey.
B. Skin lesions are part of the body structure or general appearance portion of the general
survey.
C. Speech is part of the behavior portion of the general survey
A nurse is collecting data for a client's comprehensive physical examination. after the nurse
inspects the client's abdomen, which of the following skills of the physical examination process
should she perform next?
A.olfaction
B.auscultation
C.Palpation
D.Percussion
Correct Answer: B
Rationale:
B. Because palpation and percussion can alter the frequency and intensity of bowel sounds, the
nurse should auscultate the abdomen next and before using those two techniques
,A nurse is performing a comprehensive physical examination of an older adult client. Which of
the following interventions should the nurse use in consideration of the client's age? (Select all
that apply.)
a.Collect the data in one continuous session.
B.Plan to allow plenty of time for position changes.
C.Make sure the client has any essential sensory aids in place.
D. tell the client to take her time answering questions.
E. invite the client to use the bathroom before beginning the examination
Correct Answer: B, C, D, E
Rationale:
B. Because many older adults have mobility challenges, the nurse should plan to allow extra
time for position changes.
C. the nurse should make sure clients who use sensory aids have them available for use. the
client has to be able to hear the nurse and see well enough to avoid injury.
D. Some older clients need more time to collect their thoughts and answer questions, but most
are reliable historians. Feeling rushed can hinder communication.
E. This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen
for example, but this is especially important for older clients who have a smaller bladder
capacity.
A nurse in a family practice clinic is performing a physical examination of an adult client. Which
part of her hands should she use during palpation for optimal assessment of skin temperature?
A.Palmar surface
B.Fingertips
C.Dorsal surface
, D.Base of the fingers
Correct Answer: C
Rationale:
C. The dorsal surface of the hand is the most sensitive to temperature.
A nurse is caring for an 82‑year‑old client in the emergency department who has an oral body
temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is restless
and his skin is warm. Which of the following interventions should the nurse take? (Select all that
apply.)
A.Obtain culture specimens before initiating antimicrobials.
B.Restrict the client's oral fluid intake.
C.Encourage the client to rest and limit activity.
D. allow the client to shiver to dispel excess heat.
E. assist the client with oral hygiene frequently
Correct Answer: A, C, E
Rationale:
A. he provider can prescribe cultures to identify any infectious organisms causing the fever. the
nurse should obtain culture specimens before antimicrobial therapy to prevent interference
with the detection of the infection.
C.Rest helps conserve energy and decreases metabolic rate. activity can increase heat
production
E. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips