35 terms
Ch 08
1. When performing a physical assessment, the technique the nurse will always use first is:
1. palpation.
2. inspection.
3. percussion.
4. auscultation.
1. palpation.
2. inspection.
3. percussion.
4. auscultation.
inspection.
2. The inspection phase of the physical assessment:
1. yields little information.
2. takes time and reveals a surprising amount of information.
3. may be somewhat uncomfortable for the expert practitioner.
4. requires a quick glance at the patient's body systems before proceeding on with palpation.
1. yields little information.
2. takes time and reveals a surprising amount of information.
3. may be somewhat uncomfortable for the expert practitioner.
4. requires a quick glance at the patient's body systems before proceeding on with palpation.
takes time and reveals a surprising amount of information.
3. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature?
1. Use the fingertips because they're more sensitive to small changes in temperature.
2. Use the dorsal surface of the hand because the skin is thinner than on the palms.
3. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.
4. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
1. Use the fingertips because they're more sensitive to small changes in temperature.
2. Use the dorsal surface of the hand because the skin is thinner than on the palms.
3. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.
4. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
Use the dorsal surface of the hand because the skin is thinner than on the palms.
4. Which of the following techniques uses the sense of touch when assessing a patient?
1. Palpation
2. Inspection
3. Percussion
4. Auscultation
1. Palpation
2. Inspection
3. Percussion
4. Auscultation
Palpation
5. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
1. Avoid palpation of reported "tender" areas because this may cause the patient pain.
2. Quickly palpate the area to avoid any discomfort that the patient may experience.
3. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.
4. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
1. Avoid palpation of reported "tender" areas because this may cause the patient pain.
2. Quickly palpate the area to avoid any discomfort that the patient may experience.
3. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.
4. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
6. The nurse would use bimanual palpation technique in which situation?
1. Palpating the thorax of an infant
2. Palpating the kidneys and uterus
3. Assessing pulsations and vibrations
4. Assessing the presence of tenderness and pain
1. Palpating the thorax of an infant
2. Palpating the kidneys and uterus
3. Assessing pulsations and vibrations
4. Assessing the presence of tenderness and pain
Palpating the kidneys and uterus
7. The nurse is preparing to percuss to assess the underlying:
1. tissue turgor.
2. tissue texture.
3. tissue density.
4. tissue consistency.
1. tissue turgor.
2. tissue texture.
3. tissue density.
4. tissue consistency.
tissue density.
8. The nurse is preparing to percuss the thorax of an adult. Which technique is correct?
1. Use the direct percussion technique.
2. Use the indirect percussion technique.
3. Use the ulnar surface of the hand to percuss the thorax.
4. Use the dorsal surface of the hand to percuss the thorax.
1. Use the direct percussion technique.
2. Use the indirect percussion technique.
3. Use the ulnar surface of the hand to percuss the thorax.
4. Use the dorsal surface of the hand to percuss the thorax.
Use the indirect percussion technique.
9. When percussing over the ribs of a patient, the nurse notes a dull sound. The nurse would:
1. consider this a normal finding.
2. palpate this area for an underlying mass.
3. reposition the hands and attempt to percuss in this area again.
4. consider this an abnormal finding and refer the patient for additional treatment.
1. consider this a normal finding.
2. palpate this area for an underlying mass.
3. reposition the hands and attempt to percuss in this area again.
4. consider this an abnormal finding and refer the patient for additional treatment.
consider this a normal finding.
10. 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?
1. Ask the patient to take deep breaths to relax the abdominal musculature
2. Consider this a normal finding and proceed with the abdominal assessment.
3. Increase the amount of strength used when attempting to percuss over the abdomen.
4. Decrease the amount of strength used when attempting to percuss over the abdomen.
1. Ask the patient to take deep breaths to relax the abdominal musculature
2. Consider this a normal finding and proceed with the abdominal assessment.
3. Increase the amount of strength used when attempting to percuss over the abdomen.
4. Decrease the amount of strength used when attempting to percuss over the abdomen.
Increase the amount of strength used when attempting to percuss over the abdomen.
11. The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year-old child. What should the nurse do next?
1. Palpate over the area for increased pain and tenderness.
2. Ask the child to take shallow breaths and percuss over the area again.
3. Refer the child immediately because of an increased amount of air in the lungs.
4. Consider this a normal finding for a child this age and proceed with the examination.
1. Palpate over the area for increased pain and tenderness.
2. Ask the child to take shallow breaths and percuss over the area again.
3. Refer the child immediately because of an increased amount of air in the lungs.
4. Consider this a normal finding for a child this age and proceed with the examination.
Consider this a normal finding for a child this age and proceed with the examination.
12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
1. Count the respirations and put a call in to the physician.
2. Percuss the thorax bilaterally, noting any differences in percussion tones.
3. Call for a chest x-ray and wait for the results before beginning an assessment.
4. Inspect the thorax for any new masses and bleeding associated with respirations.
1. Count the respirations and put a call in to the physician.
2. Percuss the thorax bilaterally, noting any differences in percussion tones.
3. Call for a chest x-ray and wait for the results before beginning an assessment.
4. Inspect the thorax for any new masses and bleeding associated with respirations.
Percuss the thorax bilaterally, noting any differences in percussion tones.
13. Which of the following statements is true regarding the stethoscope and its use?
1. The slope of the earpieces should point posteriorly (toward the occiput).
2. The stethoscope does not magnify sound but does block out extraneous room noise.
3. The fit and quality of the stethoscope are not as important as its ability to magnify sound.
4. The ideal tubing length should be 22 inches long to dampen distortion of sound.
1. The slope of the earpieces should point posteriorly (toward the occiput).
2. The stethoscope does not magnify sound but does block out extraneous room noise.
3. The fit and quality of the stethoscope are not as important as its ability to magnify sound.
4. The ideal tubing length should be 22 inches long to dampen distortion of sound.
The stethoscope does not magnify sound but does block out extraneous room noise.
14. Which statement is true regarding the diaphragm of the stethoscope?
1. Use the diaphragm to listen for high-pitched sounds.
2. Use the diaphragm to listen for low-pitched sounds.
3. Hold the diaphragm lightly against the person's skin to block out low-pitched sounds.
4. Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.
1. Use the diaphragm to listen for high-pitched sounds.
2. Use the diaphragm to listen for low-pitched sounds.
3. Hold the diaphragm lightly against the person's skin to block out low-pitched sounds.
4. Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.
Use the diaphragm to listen for high-pitched sounds.
15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse will:
1. warm the end piece of the stethoscope by placing it in warm water.
2. leave the gown on so that the patient does not get chilled during the examination.
3. make sure that the bell side of the stethoscope is turned to the "on" position.
4. check the temperature of the room and offer blankets to the patient if he or she feels cold.
1. warm the end piece of the stethoscope by placing it in warm water.
2. leave the gown on so that the patient does not get chilled during the examination.
3. make sure that the bell side of the stethoscope is turned to the "on" position.
4. check the temperature of the room and offer blankets to the patient if he or she feels cold.
check the temperature of the room and offer blankets to the patient if he or she feels cold.
16. Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations?
1. Palpation
2. Inspection
3. Percussion
4. Auscultation
1. Palpation
2. Inspection
3. Percussion
4. Auscultation
Palpation
17. Which of the following statements is true regarding the otoscope?
1. The otoscope is often used to direct light onto the sinuses.
2. The otoscope uses a short broad speculum to visualize the ear.
3. The otoscope is used to examine the structures of the internal ear.
4. The otoscope directs light into the ear canal and onto the tympanic membrane.
1. The otoscope is often used to direct light onto the sinuses.
2. The otoscope uses a short broad speculum to visualize the ear.
3. The otoscope is used to examine the structures of the internal ear.
4. The otoscope directs light into the ear canal and onto the tympanic membrane.
The otoscope directs light into the ear canal and onto the tympanic membrane.
18. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of the following techniques would indicate the examination is being performed correctly?
1. Using the large full circle of light when assessing pupils that are not dilated
2. Rotating the lens selector dial to the black numbers to compensate for astigmatism
3. Using the grid on the lens aperture dial to visualize the external structures of the eye
4. Rotating the lens selector dial to the red numbers to compensate for nearsightedness
1. Using the large full circle of light when assessing pupils that are not dilated
2. Rotating the lens selector dial to the black numbers to compensate for astigmatism
3. Using the grid on the lens aperture dial to visualize the external structures of the eye
4. Rotating the lens selector dial to the red numbers to compensate for nearsightedness
Rotating the lens selector dial to the red numbers to compensate for nearsightedness
19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
1. auscultate over the area with a fetoscope.
2. use a goniometer to measure the pulsations.
3. use a Doppler device to check for pulsations over the area.
4. check for the presence of pulsations with a stethoscope.
1. auscultate over the area with a fetoscope.
2. use a goniometer to measure the pulsations.
3. use a Doppler device to check for pulsations over the area.
4. check for the presence of pulsations with a stethoscope.
use a Doppler device to check for pulsations over the area.
20. When performing the physical assessment, the examiner should:
1. perform the examination from the left side of the bed.
2. examine tender or painful areas first to help relieve the patient's anxiety.
3. follow the same examination sequence regardless of the patient's age or condition.
4. organize the assessment so that the patient does not change positions too often.
1. perform the examination from the left side of the bed.
2. examine tender or painful areas first to help relieve the patient's anxiety.
3. follow the same examination sequence regardless of the patient's age or condition.
4. organize the assessment so that the patient does not change positions too often.
organize the assessment so that the patient does not change positions too often.
21. A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical exam. What steps can the examiner take to make him more comfortable?
1. Appear unhurried and confident when examining him.
2. Stay in the room when he undresses in case he needs assistance.
3. Ask him to change into an examining gown and take off his undergarments.
4. Defer measuring vital signs until the end of the examination, which allows him. time to become comfortable.
1. Appear unhurried and confident when examining him.
2. Stay in the room when he undresses in case he needs assistance.
3. Ask him to change into an examining gown and take off his undergarments.
4. Defer measuring vital signs until the end of the examination, which allows him. time to become comfortable.
Appear unhurried and confident when examining him.
22. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?
1. There is no need to wash one's hands after removing gloves, as long as the gloves are still intact.
2. Wash hands at the beginning of the examination and any time that one leaves and re-enters the room.
3. Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.
4. Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
1. There is no need to wash one's hands after removing gloves, as long as the gloves are still intact.
2. Wash hands at the beginning of the examination and any time that one leaves and re-enters the room.
3. Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.
4. Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
Wash hands at the beginning of the examination and any time that one leaves and re-enters the room.
23. The nurse is examining a patient's lower leg and notes a draining ulceration. Which of the following actions is most appropriate in this situation?
1. Wash hands and contact the physician.
2. Continue to examine the ulceration and then wash hands.
3. Wash hands, put on gloves, and continue with the examination of the ulceration.
4. Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.
1. Wash hands and contact the physician.
2. Continue to examine the ulceration and then wash hands.
3. Wash hands, put on gloves, and continue with the examination of the ulceration.
4. Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.
Wash hands, put on gloves, and continue with the examination of the ulceration.
24. During the examination, it is often appropriate to offer some brief teaching about the patient's body or one's findings. Which of the following statements by the nurse is most appropriate?
1. "Your hypertension is under control."
2. "You have pitting edema and mild varicosities."
3. "Your pulse is 80 beats per minute. This is within the normal range."
4. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."
1. "Your hypertension is under control."
2. "You have pitting edema and mild varicosities."
3. "Your pulse is 80 beats per minute. This is within the normal range."
4. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."
"Your pulse is 80 beats per minute. This is within the normal range."
25. The most important reason to share information and offer brief teaching while performing the physical examination is to help:
1. the examiner feel more comfortable and gain control of the situation.
2. build rapport and increase the patient's confidence in the examiner.
3. the patient understand his or her disease process and treatment modalities.
4. the patient identify questions about his or her disease and potential areas of patient education.
1. the examiner feel more comfortable and gain control of the situation.
2. build rapport and increase the patient's confidence in the examiner.
3. the patient understand his or her disease process and treatment modalities.
4. the patient identify questions about his or her disease and potential areas of patient education.
build rapport and increase the patient's confidence in the examiner.
26. In infants, the nurse knows to elicit the Moro reflex:
1. when the infant is sleeping.
2. at the end of the examination.
3. before auscultation of the thorax.
4. halfway through the examination.
1. when the infant is sleeping.
2. at the end of the examination.
3. before auscultation of the thorax.
4. halfway through the examination.
at the end of the examination.
27. When preparing to perform a physical examination on an infant, the examiner should:
1. have the parent remove all clothing except the diaper on a boy.
2. instruct the parent to feed the infant immediately before the exam.
3. encourage the infant to suck on a pacifier during the abdominal exam.
4. ask the parent to briefly leave the room when assessing the infant's vital signs.
1. have the parent remove all clothing except the diaper on a boy.
2. instruct the parent to feed the infant immediately before the exam.
3. encourage the infant to suck on a pacifier during the abdominal exam.
4. ask the parent to briefly leave the room when assessing the infant's vital signs.
have the parent remove all clothing except the diaper on a boy.
28. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the examiner do first?
1. Auscultate the lungs and heart while the infant is still sleeping.
2. Examine the infant's hips because this procedure is uncomfortable.
3. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
4. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
1. Auscultate the lungs and heart while the infant is still sleeping.
2. Examine the infant's hips because this procedure is uncomfortable.
3. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
4. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
Auscultate the lungs and heart while the infant is still sleeping.
29. A 2-year-old child has been brought to the clinic for a well-child check-up. How should the examiner proceed with the assessment?
1. Ask the parent to place the child on the examining table.
2. Have the parent remove all the child's clothing before the examination.
3. Allow the child to keep a security object such as a toy or blanket during the examination.
4. Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.
1. Ask the parent to place the child on the examining table.
2. Have the parent remove all the child's clothing before the examination.
3. Allow the child to keep a security object such as a toy or blanket during the examination.
4. Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.
Allow the child to keep a security object such as a toy or blanket during the examination.
30. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate?
1. Asking questions enhances the child's autonomy.
2. Asking the child for permission helps to develop a sense of trust.
3. This is an appropriate statement because children at this age like to have choices.
4. Children at this age like to say "No." The examiner should not offer a choice when there is none.
1. Asking questions enhances the child's autonomy.
2. Asking the child for permission helps to develop a sense of trust.
3. This is an appropriate statement because children at this age like to have choices.
4. Children at this age like to say "No." The examiner should not offer a choice when there is none.
Children at this age like to say "No." The examiner should not offer a choice when there is none.
31. With which of the following patients would it be most appropriate to use games during the assessment, such as, having the patient "blow out" the light on the penlight?
1. An infant
2. A preschool child
3. A school-age child
4. An adolescent
1. An infant
2. A preschool child
3. A school-age child
4. An adolescent
A preschool child
32. The nurse is preparing to examine a 4-year-old child. Which action is appropriate first?
1. Explain procedures in detail to alleviate the child's anxiety.
2. Give the child feedback and reassurance during the examination.
3. Do not ask the child to remove his clothes because children at this age are usually very private.
4. Perform an examination of the ear, nose, and throat first and then examine the thorax and abdomen.
1. Explain procedures in detail to alleviate the child's anxiety.
2. Give the child feedback and reassurance during the examination.
3. Do not ask the child to remove his clothes because children at this age are usually very private.
4. Perform an examination of the ear, nose, and throat first and then examine the thorax and abdomen.
Give the child feedback and reassurance during the examination.
33. When examining a 16-year-old male teenager, the examiner should:
1. discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness.
2. ask his parent to stay in the room during the history and physical examination to answer any questions and alleviate his anxiety.
3. talk to him the same as one would talk would a younger child because a teen's level of understanding may not match his or her speech.
4. provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
1. discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness.
2. ask his parent to stay in the room during the history and physical examination to answer any questions and alleviate his anxiety.
3. talk to him the same as one would talk would a younger child because a teen's level of understanding may not match his or her speech.
4. provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
34. When examining the aging adult, the nurse should:
1. avoid touching the patient too much.
2. attempt to perform the entire physical during one visit.
3. speak loudly and slowly because most aging adults have hearing deficits.
4. arrange the sequence to allow as few position changes as possible.
1. avoid touching the patient too much.
2. attempt to perform the entire physical during one visit.
3. speak loudly and slowly because most aging adults have hearing deficits.
4. arrange the sequence to allow as few position changes as possible.
arrange the sequence to allow as few position changes as possible.
35. The most important step that the nurse can take to prevent transmission of nosocomial infections in the hospital setting is to:
1. wear protective eye wear at all times.
2. wear gloves during any and all contact with patients.
3. wash hands before and after contact with each patient.
4. clean the stethoscope with an alcohol swab between patients.
1. wear protective eye wear at all times.
2. wear gloves during any and all contact with patients.
3. wash hands before and after contact with each patient.
4. clean the stethoscope with an alcohol swab between patients.
wash hands before and after contact with each patient.