Question 1

The nurse is unable to palpate the right radial pulse on a patient.The best action would be to:

Accepted Answer

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. 
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. C

Question 2

The nurse would use bimanual palpation technique in which situation?

Accepted Answer

A) Palpating the thorax of an infant 
B) Palpating the kidneys and uterus 
C) Assessing pulsations and vibrations 
D) Assessing the presence of tenderness and pain 
A) Palpating the thorax of an infant 
B) Palpating the kidneys and uterus 
C) Assessing pulsations and vibrations 
D) Assessing the presence of tenderness and pain B

Question 3

The nurse is preparing to assess a patient's abdomen by palpation.How should the nurse proceed?

Accepted Answer

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. 
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. D

Question 4

Which of these statements is true regarding the use of Standard Precautions in the health care setting?

Accepted Answer

A) Standard Precautions apply to all body fluids, including sweat. 
B) Use alcohol-based hand rub if hands are visibly dirty. 
C) Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. 
D) Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present. 
A) Standard Precautions apply to all body fluids, including sweat. 
B) Use alcohol-based hand rub if hands are visibly dirty. 
C) Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. 
D) Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

Question 5

The nurse is preparing to perform a physical assessment.Which statement is true about the physical assessment? The inspection phase:

Accepted Answer

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. 
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.

Question 6

When examining an infant,the nurse should examine which area first?

Accepted Answer

A) Ear 
B) Nose 
C) Throat 
D) Abdomen 
A) Ear 
B) Nose 
C) Throat 
D) Abdomen

Question 7

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?

Accepted Answer

A) Percussing once over each area 
B) Quickly lifting the 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 
A) Percussing once over each area 
B) Quickly lifting the 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

Question 8

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?

Accepted Answer

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. 
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.

Question 9

When examining a 16-year-old male teenager,the nurse should:

Accepted Answer

A) Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. 
B) Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. 
C) Talk to him the same manner as one would talk to a younger child because a teen's level of understanding may not match his or her speech. 
D) Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. 
A) Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. 
B) Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. 
C) Talk to him the same manner as one would talk to a younger child because a teen's level of understanding may not match his or her speech. 
D) Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.

Question 10

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?

Accepted Answer

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 examining gown and to take off his undergarments. 
D) Defer measuring vital signs until the end of the examination, which allows him time to become 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 examining gown and to take off his undergarments. 
D) Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

Question 11

The nurse is preparing to examine a 6-year-old child.Which action is most appropriate?

Accepted Answer

A) The thorax, abdomen, and genitalia are examined before the head. 
B) Talking about the equipment being used is avoided because doing so may increase the child's anxiety. 
C) The nurse should keep in mind that a child at this age will have a sense of modesty. 
D) The child is asked to undress from the waist up. 
A) The thorax, abdomen, and genitalia are examined before the head. 
B) Talking about the equipment being used is avoided because doing so may increase the child's anxiety. 
C) The nurse should keep in mind that a child at this age will have a sense of modesty. 
D) The child is asked to undress from the waist up.

Question 12

The nurse is preparing to perform a physical assessment.The correct action by the nurse is reflected by which statement? The nurse:

Accepted Answer

A) Performs the examination from the left side of the bed. 
B) Examines tender or painful areas first to help relieve the patient's anxiety. 
C) Follows the same examination sequence, regardless of the patient's age or condition. 
D) Organizes the assessment to ensure that the patient does not change positions too often. 
A) Performs the examination from the left side of the bed. 
B) Examines tender or painful areas first to help relieve the patient's anxiety. 
C) Follows the same examination sequence, regardless of the patient's age or condition. 
D) Organizes the assessment to ensure that the patient does not change positions too often.

Question 13

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the:

Accepted Answer

A) Examiner feel more comfortable and to gain control of the situation. 
B) Examiner to build rapport and to increase the patient's confidence in him or her. 
C) Patient understand his or her disease process and treatment modalities. 
D) Patient identify questions about his or her disease and the potential areas of patient education. 
A) Examiner feel more comfortable and to gain control of the situation. 
B) Examiner to build rapport and to increase the patient's confidence in him or her. 
C) Patient understand his or her disease process and treatment modalities. 
D) Patient identify questions about his or her disease and the potential areas of patient education.

Question 14

The nurse is examining a patient's lower leg and notices a draining ulceration.Which of these actions is most appropriate in this situation?

Accepted Answer

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 rest of the physical examination, and then continuing with the examination of the leg ulceration 
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 rest of the physical examination, and then continuing with the examination of the leg ulceration

Question 15

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

Accepted Answer

A) When the infant is sleeping 
B) At the end of the examination 
C) Before auscultation of the thorax 
D) Halfway through the examination 
A) When the infant is sleeping 
B) At the end of the examination 
C) Before auscultation of the thorax 
D) Halfway through the examination

Question 16

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress.After calling the physician and placing the patient on oxygen,which of these actions is the best for the nurse to take when further assessing the patient?

Accepted Answer

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. 
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.

Question 17

The nurse is examining a 2-year-old child and asks,"May I listen to your heart now?" Which critique of the nurse's technique is most accurate?

Accepted Answer

A) Asking questions enhances the child's autonomy 
B) Asking the child for permission helps develop a sense of trust 
C) This question is an appropriate statement because children at this age like to have choices 
D) Children at this age like to say, "No." The examiner should not offer a choice when no choice is available 
A) Asking questions enhances the child's autonomy 
B) Asking the child for permission helps develop a sense of trust 
C) This question is an appropriate statement because children at this age like to have choices 
D) Children at this age like to say, "No." The examiner should not offer a choice when no choice is available

Question 18

During an examination of a patient's abdomen,the nurse notes that the abdomen is rounded and firm to the touch.During percussion,the nurse notes a drumlike quality of the sounds across the quadrants.This type of sound indicates:

Accepted Answer

A) Constipation. 
B) Air-filled areas. 
C) Presence of a tumor. 
D) Presence of dense organs. 
A) Constipation. 
B) Air-filled areas. 
C) Presence of a tumor. 
D) Presence of dense organs.

Question 19

A 2-year-old child has been brought to the clinic for a well-child checkup.The best way for the nurse to begin the assessment is to:

Accepted Answer

A) Ask the parent to place the child on the examining table. 
B) Have the parent remove all of the child's clothing before the examination. 
C) Allow the child to keep a security object such as a toy or blanket during the examination. 
D) Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained. 
A) Ask the parent to place the child on the examining table. 
B) Have the parent remove all of the child's clothing before the examination. 
C) Allow the child to keep a security object such as a toy or blanket during the examination. 
D) Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Question 20

When preparing to perform a physical examination on an infant,the nurse should:

Accepted Answer

A) Have the parent remove all clothing except the diaper on a boy. 
B) Instruct the parent to feed the infant immediately before the examination. 
C) Encourage the infant to suck on a pacifier during the abdominal examination. 
D) Ask the parent to leave the room briefly when assessing the infant's vital signs. 
A) Have the parent remove all clothing except the diaper on a boy. 
B) Instruct the parent to feed the infant immediately before the examination. 
C) Encourage the infant to suck on a pacifier during the abdominal examination. 
D) Ask the parent to leave the room briefly when assessing the infant's vital signs.

Exam 8: Assessment Techniques and Safety in the Clinical Setting

The nurse is unable to palpate the right radial pulse on a patient.The best action would be to:

The nurse would use bimanual palpation technique in which situation?

The nurse is preparing to assess a patient's abdomen by palpation.How should the nurse proceed?

Which of these statements is true regarding the use of Standard Precautions in the health care setting?

The nurse is preparing to perform a physical assessment.Which statement is true about the physical assessment? The inspection phase:

When examining an infant,the nurse should examine which area first?

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?

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?

When examining a 16-year-old male teenager,the nurse should:

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?

The nurse is preparing to examine a 6-year-old child.Which action is most appropriate?

The nurse is preparing to perform a physical assessment.The correct action by the nurse is reflected by which statement? The nurse:

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the:

The nurse is examining a patient's lower leg and notices a draining ulceration.Which of these actions is most appropriate in this situation?

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress.After calling the physician and placing the patient on oxygen,which of these actions is the best for the nurse to take when further assessing the patient?

The nurse is examining a 2-year-old child and asks,"May I listen to your heart now?" Which critique of the nurse's technique is most accurate?

During an examination of a patient's abdomen,the nurse notes that the abdomen is rounded and firm to the touch.During percussion,the nurse notes a drumlike quality of the sounds across the quadrants.This type of sound indicates:

A 2-year-old child has been brought to the clinic for a well-child checkup.The best way for the nurse to begin the assessment is to:

When preparing to perform a physical examination on an infant,the nurse should:

Evidence-Based Assessment

Cultural Competence

The Interview

The Complete Health History

Mental Status Assessment

Substance Use Assessment

Domestic and Family Violence Assessments

General Survey, Measurement, Vital Signs

Pain Assessment: The Fifth Vital Sign

Nutritional Assessment

Skin, Hair, and Nails

Head, Face, and Neck, Including Regional Lymphatics

Eyes

Ears

Nose, Mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Musculoskeletal System

Neurologic System

Male Genitourinary System

Anus,Rectum,and Prostate

Female Genitourinary System

The Complete Health Assessment: Adult

The Complete Physical Assessment: Infant, Child, and Adolescent

Bedside Assessment of the Hospitalized Patient

The Pregnant Woman

Functional Assessment of the Older Adult

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