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Exam (elaborations)

CHAPTER 03: EXAMINATION TECHNIQUES AND EQUIPMENT

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Ball: Seidel’s Guide to Physical Examination, 9th Edition MULTIPLE CHOICE 1. According to the guidelines for Standard Precautions, the caregiver's hands should be washed: a. only after touching body fluids with ungloved hands and between patient contacts. b. only after touching blood products with ungloved hands and after caring for infectious patients. c. only after working with patients who are thought to be infectious. d. after touching any body fluids or contaminated items, regardless of whether gloves are worn. ANS: D Handwashing is to be done after removal of gloves, between patient contacts, and after touching body fluids, regardless of whether gloves are used. The nurse should never touch body fluids or blood products with ungloved hands. The nurse should use hand hygiene regardless of a patient's possible infection. DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which patient is at the highest risk for developing latex allergy? a. The new patient who has no chronic illness and has never been hospitalized b. The patient who has had multiple procedures or surgeries c. The patient who is a vegetarian d. The patient who is allergic to contrast dye ANS: B The patient who has had multiple procedures or surgeries has a higher rate of exposure to rubber gloves and to equipment and supplies that contain latex and therefore is at a higher risk for developing an allergic response. DIF: Cognitive Level: Understanding (Comprehension) OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Which technique is used during both the history taking and the physical examination process? a. Auscultation b. Inspection c. Palpation d. Percussion

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C HAPTER 03: E XAMINATION T ECHNIQUES
AND E QUIPMENT
Ball: Seidel’s Guide to Physical Examination, 9th Edition



MULTIPLE CHOICE


1. According to the guidelines for Standard Precautions, the caregiver's hands
should be washed:
a. only after touching body fluids with ungloved hands and between patient
contacts.
b. only after touching blood products with ungloved hands and after caring
for infectious patients.
c. only after working with patients who are thought to be infectious.
d. after touching any body fluids or contaminated items, regardless of
whether gloves are worn.



ANS: D



Handwashing is to be done after removal of gloves, between patient contacts,
and after touching body fluids, regardless of whether gloves are used. The
nurse should never touch body fluids or blood products with ungloved hands.
The nurse should use hand hygiene regardless of a pati ent's possible infection.

DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing
process—assessment MSC: Physiologic Integrity: Physiologic
Adaptation



2. Which patient is at the highest risk for developing latex allergy?

, a. The new patient who has no chronic illness and has never been
hospitalized
b. The patient who has had multiple procedures or surgeries
c. The patient who is a vegetarian
d. The patient who is allergic to contrast dye



ANS: B



The patient who has had multiple procedures or surgeries has a highe r rate of
exposure to rubber gloves and to equipment and supplies that contain latex
and therefore is at a higher risk for developing an allergic response.



DIF: Cognitive Level: Understanding (Comprehension) OBJ: Nursing
process—assessment MSC: Physiologic Integrity: Physiologic
Adaptation



3. Which technique is used during both the history taking and the physical
examination process?
a. Auscultation
b. Inspection
c. Palpation
d. Percussion



ANS: B



Inspection is the technique that is used while gathering and valida ting data
during both the history taking and the actual hands -on physical examination.
Auscultation, palpation, and percussion are not used during the history taking
and physical examination processes. It is not possible to listen to the patient
talking and use the stethoscope at the same time. The focus is on the patient's

, response to your touch and what you are feeling; it is not possible to perform
palpation and listen to the patient talking at the same time.



DIF: Cognitive Level: Understanding (Comprehension) OBJ: Nursing
process—assessment MSC: Physiologic Integrity: Physiologic
Adaptation



4. The use of secondary, tangential lighting is most helpful in the detection of:
a. variations in skin color.
b. enlarged tonsils.
c. foreign objects in the nose or ear.
d. variations in contour of the body surface.



ANS: D



Tangential lighting is used to cast shadows to observe contours and variations
in body surfaces best.



DIF: Cognitive Level: Understanding (Comprehension) OBJ: Nursing
process—assessment MSC: Physiologic Integrity: Physiologic
Adaptation



5. You are caring for a nonambulatory 80-year-old male patient and he tells you, a
female nurse, that he feels like he is having drainage from his rectum. Which
initial nursing action is appropriate?
a. Drape the patient and observe the rectal area.
b. Tell the patient that his doctor will be notified of his problem.
c. Tell the patient that you will ask the male nurse on the next shift to check
on the problem.
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