Question 1

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child.The nurse should:

Accepted Answer

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 a normal finding for a child this age and proceed with the examination. 
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 a normal finding for a child this age and proceed with the examination. D

Question 2

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 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 is avoided because palpation in these areas may cause pain. 
B) Palpating a tender area is quickly performed to avoid causing any discomfort to the patient. 
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 is avoided because palpation in these areas may cause pain. 
B) Palpating a tender area is quickly performed to avoid causing any discomfort to the patient. 
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

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

Accepted Answer

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 spread 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 diseases. 
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 spread 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 diseases.

Question 5

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

Accepted Answer

A) Auscultate the lungs and heart while the infant is still sleeping 
B) Examine the infant's hips because this procedure is uncomfortable 
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 portion 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 because this procedure is uncomfortable 
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 portion of the examination to obtain the most accurate assessment of body systems

Question 6

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 7

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate.Which one of these statements by the nurse is most appropriate?

Accepted Answer

A) "Your atrial dysrhythmia is 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'm using my stethoscope to listen for any crackles, wheezes, or rubs." 
A) "Your atrial dysrhythmia is 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'm using my stethoscope to listen for any crackles, wheezes, or rubs."

Question 8

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 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 9

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 10

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 build rapport and 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 build rapport and 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 11

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.

Question 12

The nurse is assessing a patient admitted for Clostridium difficile infection.What must the nurse do when leaving the patient's room?

Accepted Answer

A) Perform hand hygiene with an alcohol-based hand rub 
B) Replace gloves with a clean pair 
C) Perform hand hygiene with soap-and-water handwashing 
D) Remove mask 
A) Perform hand hygiene with an alcohol-based hand rub 
B) Replace gloves with a clean pair 
C) Perform hand hygiene with soap-and-water handwashing 
D) Remove mask

Question 13

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 the "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 the "no" choice is available.

Question 14

When percussing over the liver of a patient, the nurse observes a dull sound.The nurse should:

Accepted Answer

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 an abnormal finding and refer the patient for additional treatment. 
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 an abnormal finding and refer the patient for additional treatment.

Question 15

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 16

The nurse is preparing to use an otoscope for an examination.Which statement is true regarding the otoscope? The otoscope:

Accepted Answer

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. 
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.

Question 17

The nurse will use which technique of assessment 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

Question 18

The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:

Accepted Answer

A) Wear protective eye wear at all times. 
B) Wear gloves during any and all contact with patients. 
C) Wash hands before and after contact with each patient. 
D) Clean the stethoscope with an alcohol swab between patients. 
A) Wear protective eye wear at all times. 
B) Wear gloves during any and all contact with patients. 
C) Wash hands before and after contact with each patient. 
D) Clean the stethoscope with an alcohol swab between patients.

Question 19

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

Accepted Answer

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

Question 20

When performing a physical assessment, the first technique the nurse will always use is:

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

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child.The nurse should:

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

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

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

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

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

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate.Which one of these statements by the nurse is most appropriate?

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 best for the nurse to take when further assessing the patient?

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

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:

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

The nurse is assessing a patient admitted for Clostridium difficile infection.What must the nurse do when leaving the patient's room?

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?

When percussing over the liver of a patient, the nurse observes a dull sound.The nurse should:

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?

The nurse is preparing to use an otoscope for an examination.Which statement is true regarding the otoscope? The otoscope:

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:

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

When performing a physical assessment, the first technique the nurse will always use is:

Evidence-Based Assessment

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Health Assessment

Substance Use and Health Assessment

Interpersonal Violence Assessments

General Survey, Measurement, Vital Signs

Pain Assessment

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

Anus, Rectum, and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Adult, Infant, Child, and Adolescent

Bedside Assessment of the Hospitalized Patient

The Pregnant Woman

Functional Assessment of the Older Adult

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