When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?

Correct Answer: B

Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.

Correct Answer: C

Rationale: During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient. Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.

Correct Answer: B

Rationale: Sharing information and briefly teaching the patient during a physical examination helps build rapport and increase the patient's confidence in the examiner. This approach gives the patient a sense of control in a situation that can often be overwhelming. While sharing information may make the patient feel more comfortable, the primary goal is to enhance the patient's confidence in the examiner. Providing information does not necessarily directly assist the patient in understanding their disease process and treatment modalities, as this may require a more in-depth explanation. The main focus is on establishing a trusting relationship and empowering the patient during the examination, rather than solely aiding in identifying questions or areas needing education.

Correct Answer: B

Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.

Correct Answer: C

Rationale: The thyroid gland is responsible for secreting thyroxine (T4) and triiodothyronine (T3), which work to regulate the metabolism of the body's cells. The primary function of the thyroid gland is to control the body's metabolic rate, affecting processes such as heart rate, temperature regulation, and energy levels. Choices A, B, and D are incorrect because the thyroid gland is not involved in converting glucose into glycogen, secreting cortisol, or affecting skin pigmentation. Instead, the primary role of the thyroid gland is to regulate the metabolism and energy balance in the body.