The nurse is preparing to conduct a head-to-toe physical assessment. Which considerations will allow for a safe and appropriate physical assessment environment?
Family members should always be present
There are no special considerations when conducting a physical assessment
The door to the room is left open
The room is private, warm, with adequate lighting
The Correct Answer is D
A. Family members should always be present: Family presence is optional and should depend on patient preference and confidentiality concerns - it is not mandatory.
B. There are no special considerations when conducting a physical assessment: Physical assessments require attention to privacy, patient comfort, and safety - so special considerations do apply.
C. The door to the room is left open: Leaving the door open can breach privacy and confidentiality and may make the patient uncomfortable.
D. The room is private, warm, with adequate lighting: A private, warm room with good lighting promotes patient comfort, dignity, and an accurate examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Opening of pulmonary and aortic valves: Valve opening is not what produces the heart sounds heard with a stethoscope; heart sounds relate to valve closure.
B. Opening of tricuspid and mitral valves: The sounds detected on auscultation are associated with valve closure events rather than openings.
C. Closure of tricuspid and mitral valves: S1 is produced by the closure of the atrioventricular valves (mitral and tricuspid) at the start of ventricular systole.
D. Closure of pulmonary and aortic valves: Closure of the semilunar valves (aortic and pulmonic) produces S2, which occurs at the end of systole.
Correct Answer is D
Explanation
A. Family members should always be present: Family presence is optional and should depend on patient preference and confidentiality concerns - it is not mandatory.
B. There are no special considerations when conducting a physical assessment: Physical assessments require attention to privacy, patient comfort, and safety - so special considerations do apply.
C. The door to the room is left open: Leaving the door open can breach privacy and confidentiality and may make the patient uncomfortable.
D. The room is private, warm, with adequate lighting: A private, warm room with good lighting promotes patient comfort, dignity, and an accurate examination.
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