Deck 5: Assessment Techniques

Question 1

You are assessing an elderly man who is in isolation for a respiratory illness. He has a large abdominal dressing that needs to be changed. What will you need to wear prior to entering the room and during the assessment? Select all that apply.

A) Gown
B) Mask
C) Paper shoe covers
D) Gloves
E) Eye protector

Answer 1

Gown
Mask
Gloves
Eye protector

Question 2

What is the purpose of the assessment technique of inspection? Select all that apply.

A) To assess physical characteristics
B) To assess orientation
C) To assess posture
D) To assess appearance
E) To assess behavior

Answer 2

To assess physical characteristics
To assess posture
To assess appearance
To assess behavior

Question 3

A nurse is performing a general assessment. What is he or she assessing when performing light palpation? Select all that apply.

A) Skin textures
B) Masses
C) Tenderness
D) Abdominal organs
E) Color

Answer 3

Skin textures
Masses
Tenderness

Question 4

What is the purpose of direct percussion? Select all that apply.

A) To assess for tenderness
B) To assess borders of an organ
C) To assess density of tissue
D) To assess presence of fluid
E) To assess lung sounds

Question 5

The patient is complaining of shortness of breath and mild chest pain. You are about to start the focused assessment. What should be the nurse's first action?

A) Auscultate lung sounds.
B) Auscultate heart sounds.
C) Wash hands in front of patient.
D) Call for help immediately.

Question 6

You are performing an admission assessment on a patient who is scheduled for open heart surgery tomorrow. He reports that he has an allergy to latex products. Which of the following measures is of highest priority?

A) Educate the patient on the signs and symptoms of the latex allergy.
B) Document the patient has a latex allergy and symptoms of the allergy.
C) Give the patient a list of latex products used in the hospital.
D) Notify the surgeon and operating room staff.

Question 7

Which of the following is the best approach when performing a health assessment?

A) An organized approach, working from noninvasive to invasive assessments
B) A head-to-toe approach, working from the core to the extremities
C) A systems approach, working from the neurological to the musculoskeletal
D) A strict approach, depending on the age of the patient

Question 8

Palpation is used to assess every system. There are two types of palpation. The part of the hands used to palpate vibrations is the:

A) Fingertips.
B) Finger pads.
C) Ball or ulnar surface of the hands.
D) Dorsal aspect of the hands.

Question 9

You are assessing a patient's skin and note what appears to be a small, discolored lesion on the patient's right cheek. What would be your next nursing action?

A) Turn up the fluorescent lighting to better evaluate the lesion.
B) Document a small, discolored lesion on right cheek.
C) Continue to assess the rest of the patient's skin.
D) Reassess using tangential lighting.

Question 10

A patient comes to the urgent care center stating that he feels his left leg is swollen. A fundamental assessment guideline when inspecting his left leg is which of the following?

A) Expose only the patient's left leg and keep his other leg unexposed.
B) Compare the symmetry of body parts from one side to the other side.
C) Using the ulnar surface of your hand, feel the temperature of the skin of his left leg.
D) Measure the left leg to assess calf circumference.

Question 11

The patient complains that he has not voided in 24 hours. You are assessing the bladder. What would be the best technique to assess a distended bladder?

A) Inspection
B) Percussion
C) Single-handed light palpation
D) Bimanual deep palpation

Question 12

You are performing light and deep palpation on the patient's abdomen. You know that you will press down ________ for light palpation and ________ for deep palpation.

A) 1 cm; 5 cm
B) 2 cm; 4 cm
C) 3 cm; 4 cm
D) 4 cm; 5 cm

Question 13

Health assessment requires the collection of data to accurately and safely care for every patient. What is the correct sequence of assessment techniques that will provide objective assessment data (1-4)? (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.)
____1. Palpation
____2. Auscultation
____3. Inspection
____4. Percussion

Question 14

The nurse enters the room of a patient and encounters a strong foul odor. This is an example of ____________________ inspection.

Question 15

You are percussing over the posterior lobes of the lungs. The lungs are healthy and normal. The percussion sound of normal healthy lungs is called ________________.