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The Nurse Is Preparing to Assess an Adult Client Who

Question 23

Multiple Choice

The nurse is preparing to assess an adult client who presents to the emergency room after falling down some steps at home.The client complains of left ankle pain and has open abrasions to the left knee and shin.Which of the following should the nurse incorporate into the physical assessment of this client?


A) Wash hands in the presence of the client.
B) Put on nonsterile gloves to examine the client.
C) Ensure that the client has an empty bladder before beginning the physical assessment.
D) Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
E) Assess only the left lower extremity since this is the injured body part.

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