When performing a physical assessment, the first technique the nurse will always use
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
... [Show More] Correct Answer- B. Inspection
The nurse is preparing to perform a physical assessment. Which statement is true about the physical
assessment? The inspection phase:
A. Usually yields little information
B. Takes time and reveals a surprising amount of information
C. May be somewhat uncomfortable for the expert practitioner
D. Requires a quick glance at the patient's body systems before proceeding with palpation Correct
Answer- B. Takes time and reveals a surprising amount of information
The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should
be used to best assess the patient's skin temperature?
A. Fingertips; they are more sensitive to small changes in temperature
B. Dorsal surface of the hand; the skin is thinner on this surface than on the palms
C. Ulnar portion of the hand, increased blood supply in this area enhances temperature sensitivity
D. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its
increased nerve supply in this area. Correct Answer- B. Dorsal surface of the hand; the skin is thinner on
this surface than on the palms
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and
swelling when the nurse is assessing a patient?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation Correct Answer- A. Palpation
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
A. Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain
B. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience
C. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep
breaths.
D. The assessment begins with light palpation to detect surface characteristics and to accustom the
patient to being touched. Correct Answer- D. The assessment begins with light palpation to detect
surface characteristics and to accustom the patient to being touched.
The nurse would use bimanual palpation technique in which situation?
A. Palpating the thorax of an infant
B. Palpating the kidneys and the uterus
C. Assessing pulsations and vibrations
D. Assessing the presence of tenderness and pain Correct Answer- B. Palpating the kidneys and the
uterus
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess
the ___________ of the underlying tissue.
A. Turgor
B. Texture
C. Density
D. Consistency Correct Answer- C. Density
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by
the new nurse, indicates that more review is needed?
A. Percussing once over each area
B. Quickly lifting be striking finger after each stroke
C. Striking with the fingertip, not the finger pad
D. Using the wrist to make the strikes, not the arm Correct Answer- A. Percussing once over each area
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
A. Consider this a normal finding
B. Palpate this area for an underlying mass
C. Reposition the hands, and attempt to percuss in this area again
D. Consider this finding abnormal, and refer the patient for additional treatment Correct Answer- A.
Consider this a normal finding
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese
patient. What should the nurse do next?
A. Ask the patient to take deep breaths to relax the abdominal musculature
B. Consider this finding as normal and proceed with the abdominal assessment
C. Increase the amount of strength used when attempting to percuss over the abdomen
D. Decrease the amount of strength used when attempting to percuss over the abdomen. Correct
Answer- C. Increase the amount of strength used when attempting to percuss over the abdomen
The nurse hears bilateral loud, long and low tones when percussing over the lungs of a 4 year old child.
The nurse should
A. Palpate over the area for increased pain and tenderness
B. Ask the child to take shallow breaths and percuss over the area again
C. Immediately refer the child because of an increased amount of air in the lungs
D. Consider this finding as normal for a child this age and proceed with the examination Correct AnswerD. Consider this finding as normal for a child this age and proceed with the examination
A patient has suddenly developed shortness of breath and appears to be insignificant respiratory
distress. After calling the position and placing the patient on oxygen, which of these actions is the best
for the nurse to take went further assisting this patient?
A. Count the patient's respirations
B. Bilaterally percuss the thorax, noting any differences in percussion tones
C. Call for a chest x-ray study and wait for the results before beginning an assessment
D. Inspect the thorax for any new masses and bleeding associated with respirations Correct Answer- B.
Bilaterally percuss the thorax, noting any differences in percussion tones
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the
stethoscope and its use?
A. Slope of the earpieces should point posteriorly (toward to occiput)
B. Although the stethoscope does not magnify sound, it does block out extraneous room noise
C. Fit and quality of the stethoscope are not as important as its ability to magnify sound
D. Ideal tubing length should be 22 inches to dampen the distortion of sound Correct Answer- B.
Although the stethoscope does not magnify sound, it does block out extraneous room noise
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the
diaphragm of the stethoscope? The diaphragm:
A. Is used to listen for high-pitched sounds
B. Is used to listen for low-pitched sounds
C. Should be lightly held against the persons skin to block out low-pitched sounds
D. Should be lightly held again the person skin to listen for extra heart sounds and murmurs Correct
Answer- A. Is used to listen for high-pitched sounds
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
A. Warm the endpiece of the stethoscope by placing it in warm water
B. Leave the gown on the patient to ensure that she or he does not get chilled during the examination
C. Ensure that the bell side of the stethoscope is turned to the on position
D. Check the temperature of the room and offer blankets to the patient if she or he feels cold. Correct
Answer- D. Check the temperature of the room and offer blankets to the patient if she or he feels cold.
The nurse will use which technique of assessment to determine the presence of crepitus, swelling and
pulsations?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation Correct Answer- A. Palpation
The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the
otoscope? The otoscope:
A. Is often used to direct light onto the sinuses
B. Uses a short, broad speculum to help visualize the ear
C. Is used to examine the structures of the internal ear
D. Directs light into the ear canal and onto the tympanic membrane Correct Answer- D. Directs light into
the ear canal and onto the tympanic membrane
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is
nearsighted. The use of which of these techniques would indicate that the examination is being correctly
performed?
A. Using the large full circle of light when assessing pupils that are not dilated
B. Rotating the lens selector dial to the black numbers to compensate for astigmatism
C. Using the grid on the lens aperture to visualize the external structures of the eye
D. Rotating the lens selector dial to bring the object into focus Correct Answer- D. Rotating the lens
selector dial to bring the object into focus
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
A. Auscultate over the area with a fetoscope
B. Use a goniometer to measure the pulsations
C. Use a Doppler device to check for pulsations over the area
D. Check for the presence of pulsations with a stethoscope Correct Answer- C. Use a Doppler device to
check for pulsations over the area
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by
which statement? The nurse:
A. Performs the examination from the left side of the bed
B. Examines the tender of painful areas first to help relieve the patient's anxiety
C. Follows the same examination sequence, regardless of the patients age or condition
D. Organizes the assessment to ensure that the patient does not change positions too often Correct
Answer- D. Organizes the assessment to ensure that the patient does not change positions too often
A man is at the clinic for a physical examination. He states that he is very anxious about the physical
examination. What steps can the nurse take to make him more comfortable?
A. Appear unhurried and confident when examining him
B. Stay in the room when he undresses in case he needs assistance
C. Ask him to change into an examination gown to take off his undergarments
D. Defer measuring vital signs until the end of the examination which allows him time to become
comfortable Correct Answer- A. Appear unhurried and confident when examining him
When performing a physical examination, safety must be considered to protect the examiner in the
patient against the spread of the infection. Which of these statements describes the most appropriate
action the nurse should take when performing a physical examination ?
A. Washing one's hands after removing gloves is not necessary, as long as the gloves are still intact
B. Hands are washed before and after every physical patient encounter
C. Hands are washed before the examination of each body system to prevent the spirit of bacteria from
one part of the body to another
D. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding
the spread of infectious disease Correct Answer- B. Hands are washed before and after every physical
patient encounter
The nurses examining a patient lower leg and notices a training ulceration. Which of these actions is
most appropriate in this situation?
A. Washing hands and contacting the physician
B. Continuing to examine the ulceration, and then washing hands
C. Washing hands, putting on gloves, and continuing with the examination of the ulceration
D. Washing hands, proceeding with the rest of the physical examination, and then continuing with the
examination of the leg ulceration Correct Answer- C. Washing hands, putting on gloves, and continuing
with the examination of the ulceration
During the examination offering some brief teaching about the patient's body or examiners finding is
often appropriate. Which one of these statements by the nurse is most appropriate?
A. Your atrial dysrhythmias are under control
B. You have pitting edema and mild varicosities
C. Your pulse is 80 beats per minute which is within the normal range
D. I am using my stethoscope to listen for any crackles, wheezes or rubs Correct Answer- C. Your pulse is
80 beats per minute which is within the normal range [Show Less]