Question 1

During auscultation of a patient's heart,the nurse hears an unfamiliar sound.What should the nurse do next?

Accepted Answer

A) Document the findings on the patient's record. 
B) Wait 10 minutes,and auscultate the heart again. 
C) Ask how the patient is feeling. 
D) Ask another nurse to double-check the finding. 
A) Document the findings on the patient's record. 
B) Wait 10 minutes,and auscultate the heart again. 
C) Ask how the patient is feeling. 
D) Ask another nurse to double-check the finding. D

Question 2

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

Accepted Answer

A) Avoid palpation of reported "tender" areas because this may cause pain to the patient. 
B) Palpate the area quickly to avoid causing any discomfort to the patient. 
C) Begin the assessment with deep palpation,encouraging the patient to relax and take deep breaths. 
D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. 
A) Avoid palpation of reported "tender" areas because this may cause pain to the patient. 
B) Palpate the area quickly to avoid causing any discomfort to the patient. 
C) Begin the assessment with deep palpation,encouraging the patient to relax and take deep breaths. 
D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. D

Question 3

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

Accepted Answer

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

Question 4

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

Accepted Answer

A) discuss health education 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-taking and physical examination to answer any questions and alleviate his anxiety. 
C) talk to him in the same way 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 variations among teenagers in the rates of growth and development. 
A) discuss health education 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-taking and physical examination to answer any questions and alleviate his anxiety. 
C) talk to him in the same way 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 variations among teenagers in the rates of growth and development.

Question 5

When examining infants,the nurse will elicit the Moro reflex:

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 6

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

Accepted Answer

A) Asking questions enhances the child's autonomy. 
B) Asking the child's permission helps create a sense of trust. 
C) This is an appropriate approach 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 there is none. 
A) Asking questions enhances the child's autonomy. 
B) Asking the child's permission helps create a sense of trust. 
C) This is an appropriate approach 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 there is none.

Question 7

The nurse is examining a patient's lower leg and notes a draining ulcer.Which of the following actions is most appropriate in this situation?

Accepted Answer

A) Wash hands first,and then contact the physician. 
B) Continue to examine the ulcer,and then wash hands. 
C) Wash hands,put on gloves,and continue with the examination of the ulcer. 
D) Wash hands,proceed with rest of the physical examination,and then go on to the examination of the ulcer. 
A) Wash hands first,and then contact the physician. 
B) Continue to examine the ulcer,and then wash hands. 
C) Wash hands,put on gloves,and continue with the examination of the ulcer. 
D) Wash hands,proceed with rest of the physical examination,and then go on to the examination of the ulcer.

Question 8

MATCHING
The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation.

-The dorsa (backs)of hands and fingers

Accepted Answer

A) Should be used to detect the shape and consistency of a mass in the axilla 
B) Best for evaluating skin texture over the abdomen. 
C) Used to determine the temperature of the patient's skin. 
D) Best for detecting vibration over the thorax and abdomen. 
A) Should be used to detect the shape and consistency of a mass in the axilla 
B) Best for evaluating skin texture over the abdomen. 
C) Used to determine the temperature of the patient's skin. 
D) Best for detecting vibration over the thorax and abdomen.

Question 9

The nurse is assessing a patient's skin during an office visit.What is the best technique to use to best assess skin temperature?

Accepted Answer

A) Use the fingertips because they are more sensitive to small changes in skin temperature. 
B) Use the dorsal surface of the hand because the skin is thinner there than on the palms. 
C) Use the ulnar portion of the hand because of its increased blood supply that enhances sensitivity to temperature. 
D) Use the palmar surface of the hand because its increased nerve supply makes it the most sensitive to skin temperature variations. 
A) Use the fingertips because they are more sensitive to small changes in skin temperature. 
B) Use the dorsal surface of the hand because the skin is thinner there than on the palms. 
C) Use the ulnar portion of the hand because of its increased blood supply that enhances sensitivity to temperature. 
D) Use the palmar surface of the hand because its increased nerve supply makes it the most sensitive to skin temperature variations.

Question 10

The inspection phase of the physical assessment:

Accepted Answer

A) 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 to palpation. 
A) 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 to palpation.

Question 11

MATCHING
The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation.

-Fingers and thumb in a grasping action

Accepted Answer

A) Should be used to detect the shape and consistency of a mass in the axilla 
B) Best for evaluating skin texture over the abdomen. 
C) Used to determine the temperature of the patient's skin. 
D) Best for detecting vibration over the thorax and abdomen. 
A) Should be used to detect the shape and consistency of a mass in the axilla 
B) Best for evaluating skin texture over the abdomen. 
C) Used to determine the temperature of the patient's skin. 
D) Best for detecting vibration over the thorax and abdomen.

Question 12

The nurse is preparing to percuss the thorax of an adult.Which one of the following techniques is the correct one to use?

Accepted Answer

A) Direct percussion 
B) Indirect percussion 
C) Using the ulnar surface of the hand 
D) Using the dorsal surface of the hand 
A) Direct percussion 
B) Indirect percussion 
C) Using the ulnar surface of the hand 
D) Using the dorsal surface of the hand

Question 13

A 6-month-old infant has been brought to the well-child clinic for a checkup.She is currently sleeping.What should the examiner do first?

Accepted Answer

A) Auscultate the lungs and heart while the infant is still sleeping. 
B) Examine the infant's hips when the infant is still asleep because this procedure usually causes discomfort. 
C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. 
D) Wake the infant before beginning any part of the examination to obtain the most accurate assessment of body systems. 
A) Auscultate the lungs and heart while the infant is still sleeping. 
B) Examine the infant's hips when the infant is still asleep because this procedure usually causes discomfort. 
C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. 
D) Wake the infant before beginning any part of the examination to obtain the most accurate assessment of body systems.

Question 14

Which of the following statements about the otoscope is true?

Accepted Answer

A) The otoscope is often used to direct light onto the sinuses. 
B) The otoscope has a short,broad speculum to be used in visualizing the ear. 
C) The otoscope is used to examine the structures of the internal ear. 
D) The otoscope directs light into the ear canal and onto the tympanic membrane. 
A) The otoscope is often used to direct light onto the sinuses. 
B) The otoscope has a short,broad speculum to be used in visualizing the ear. 
C) The otoscope is used to examine the structures of the internal ear. 
D) The otoscope directs light into the ear canal and onto the tympanic membrane.

Question 15

The nurse is preparing to percuss to assess the underlying:

Accepted Answer

A) tissue turgor. 
B) tissue texture. 
C) tissue density. 
D) tissue consistency. 
A) tissue turgor. 
B) tissue texture. 
C) tissue density. 
D) tissue consistency.

Question 16

Which of the following techniques involves the use of the sense of touch when assessing a patient?

Accepted Answer

A) Palpation 
B) Inspection 
C) Percussion 
D) Auscultation 
A) Palpation 
B) Inspection 
C) Percussion 
D) Auscultation

Question 17

Which of the following statements about the application of routine practices in the health care setting is true?

Accepted Answer

A) Routine practices apply to all instances of contact with body fluids,including sweat. 
B) Airborne,droplet,and contact transmission-based precautions are included in routine practices. 
C) Routine practices should be followed in the case of all patients regardless of their risk or presumed infection status. 
D) Routine practices are to be followed only when there is nonintact skin,excretions contain visible blood,or contact with mucous membranes is expected. 
A) Routine practices apply to all instances of contact with body fluids,including sweat. 
B) Airborne,droplet,and contact transmission-based precautions are included in routine practices. 
C) Routine practices should be followed in the case of all patients regardless of their risk or presumed infection status. 
D) Routine practices are to be followed only when there is nonintact skin,excretions contain visible blood,or contact with mucous membranes is expected.

Question 18

During the examination,it is often appropriate to offer some education to the patient about the findings.Which of the following statements by the nurse is most appropriate?

Accepted Answer

A) "Your hypertension is under control." 
B) "You have pitting edema and mild varicosities." 
C) "Your pulse is 80 beats per minute.This is within the normal range." 
D) "I'm using my stethoscope to listen for any crackles,wheezes,or rubs." 
A) "Your hypertension is under control." 
B) "You have pitting edema and mild varicosities." 
C) "Your pulse is 80 beats per minute.This is within the normal range." 
D) "I'm using my stethoscope to listen for any crackles,wheezes,or rubs."

Question 19

When performing a physical examination,safety measures must be taken to protect the examiner and the patient against infections.Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?

Accepted Answer

A) There is no need to wash hands after removing gloves,as long as the gloves are still intact. 
B) Wash hands at the beginning of the examination and every time you leave and re-enter the room. 
C) Wash hands between examinations of body systems to prevent the spread of pathogens from one part of the body to another. 
D) Wear gloves through the entire examination to reassure the patient that you are careful about the spread of infectious diseases. 
A) There is no need to wash hands after removing gloves,as long as the gloves are still intact. 
B) Wash hands at the beginning of the examination and every time you leave and re-enter the room. 
C) Wash hands between examinations of body systems to prevent the spread of pathogens from one part of the body to another. 
D) Wear gloves through the entire examination to reassure the patient that you are careful about the spread of infectious diseases.

Question 20

Which of the following assessment techniques is used to determine the presence of crepitus,swelling,and pulsations?

Accepted Answer

A) Palpation 
B) Inspection 
C) Percussion 
D) Auscultation 
A) Palpation 
B) Inspection 
C) Percussion 
D) Auscultation

Exam 9: Assessment Techniques and the Clinical Setting

During auscultation of a patient's heart,the nurse hears an unfamiliar sound.What should the nurse do next?

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

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

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

When examining infants,the nurse will elicit the Moro reflex:

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

The nurse is examining a patient's lower leg and notes a draining ulcer.Which of the following actions is most appropriate in this situation?

MATCHING The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation. -The dorsa (backs)of hands and fingers

The nurse is assessing a patient's skin during an office visit.What is the best technique to use to best assess skin temperature?

The inspection phase of the physical assessment:

MATCHING The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation. -Fingers and thumb in a grasping action

The nurse is preparing to percuss the thorax of an adult.Which one of the following techniques is the correct one to use?

A 6-month-old infant has been brought to the well-child clinic for a checkup.She is currently sleeping.What should the examiner do first?

Which of the following statements about the otoscope is true?

The nurse is preparing to percuss to assess the underlying:

Which of the following techniques involves the use of the sense of touch when assessing a patient?

Which of the following statements about the application of routine practices in the health care setting is true?

During the examination,it is often appropriate to offer some education to the patient about the findings.Which of the following statements by the nurse is most appropriate?

When performing a physical examination,safety measures must be taken to protect the examiner and the patient against infections.Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?

Which of the following assessment techniques is used to determine the presence of crepitus,swelling,and pulsations?

Critical Thinking and Evidence-Informed Assessment

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care and Social Considerations in Health Assessment

The Interview

The Complete Health History

Mental Health Assessment

Substance Use in the Context of Health Assessment

Interpersonal Violence Assessment

General Survey, measurement, and Vital Signs

Pain Assessment

Nutritional Assessment and Nursing Practice

Skin, hair, and Nails

Head and Neck, including Regional Lymphatic System

Eyes

Ears

Nose, mouth, and Throat

Breasts and Regional Lymphatic System

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Anus,rectum and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Bedside Assessment of the Hospitalized Patient

Pregnancy

Functional Assessment of the Older Adult

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