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and watching for tremors is the method for assessing the function of cranial nerve XII (hypoglossal nerve). Assessment of pharyngeal function reveals the function of cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve).
A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?Ask health history questions while performing the examination and initiating emergency measuresRationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address thepriority, which is treating the client. Collecting all data requested on the history does not specifically address the client's immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment.A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurseperforms this assessment by:Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"Rationale: Palpation over the lung is used to assess tactile (vocal) fremitus. The nurse begins by palpatingover the lung apices in the supraclavicular areas. The nurse compares vibrations from side to side as the client repeats the word "ninety-nine." To palpate for symmetric chest expansion, the nurse places the hands on the anterolateral wall, with the thumbs along the costal margins and pointing toward the xiphoid process. The client is asked to take a deep breath; as he or she does so, the nurse watches his or her thumbs move apart and watches for symmetry. Auscultation of breath sounds over the trachea and larynx is used to assess bronchial breath sounds. Auscultation of breath sounds over the peripheral lung fields is used to assess vesicular breath sounds.When conducting a physical examination of an adult client, in what order does the nurse perform the various assessment techniques? Number 1 is the first technique performed and number 4 is the last technique performed.The correct order is:Inspection Palpation Percussion Auscultation
Rationale: The assessment techniques used to perform a physical examination are inspection, palpation, percussion, and auscultation. These activities are performed one at a time and in this order. The exception is abdominal assessment, in which the nurse would inspect and then auscultate, because percussion and palpation can cause peristalsis, which could cause the examiner to make a false interpretation of bowel sounds.