The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is A
Explanation
A. Having the child bend at the waist allows the nurse to observe the spine for any abnormal curvature indicative of scoliosis, such as uneven shoulders or a rib hump.
B. Measuring the distance between the knees and the ankles is not a technique used to screen for scoliosis; it is more related to assessing leg length discrepancies.
C. Measuring the length of each leg does not assess for scoliosis but is more relevant for evaluating leg length inequalities.
D. Asking the child to walk across the room is useful for assessing gait and balance but does not directly assess for scoliosis.
Correct Answer is B
Explanation
A. A pulse oximeter is used to measure oxygen saturation and is not relevant to cochlear dysfunction.
B. A hearing aid is appropriate for someone with cochlear dysfunction as it can help amplify sound and improve hearing, indicating the client is adapting to the hearing loss.
C. Eyeglasses are used for vision problems and do not relate to the function of the cochlear division of the vestibulocochlear nerve.
D. A bath thermometer is used to measure water temperature and is not relevant to auditory issues.