Deck 8: Assessment Techniques and the Clinical Setting

Question 1

The nurse is preparing to use a stethoscope for auscultation.Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:

A) is used to listen for high-pitched sounds.
B) is used to listen for low-pitched sounds.
C) should be held lightly against the person's skin to block out low-pitched sounds.
D) should be held lightly against the person's skin to listen for extra heart sounds and murmurs.

Answer 1

is used to listen for high-pitched sounds.

Question 2

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?

A) Ask the patient to take deep breaths to relax the abdominal musculature.
B) Consider this a normal finding and proceed with the abdominal assessment.
C) Increase the amount of strength used when attempting to percuss over the abdomen.
D) Decrease the amount of strength used when attempting to percuss over the abdomen.

Answer 2

Increase the amount of strength used when attempting to percuss over the abdomen.

Question 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? Use the:

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

Answer 3

dorsal surface of the hand because the skin is thinner than on the palms.

Question 4

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:

A) percusses once over each area.
B) lifts the striking finger off quickly after each stroke.
C) strikes with the finger tip, not the finger pad.
D) uses the wrist to make the strikes, not the arm.

Question 5

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

A) Avoid palpation of reported "tender" areas because this may cause the patient pain.
B) Quickly palpate a tender area to avoid any discomfort that the patient may experience.
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.

Question 6

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

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 7

Which of these techniques uses the sense of touch to assess texture,temperature,moisture,and swelling when the nurse is assessing a patient?

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

Question 8

The nurse would use bimanual palpation technique in which situation?

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

Question 9

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

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.

Question 10

The nurse is preparing to percuss the abdomen of a patient.The purpose of the percussion is to assess the underlying tissue:

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

Question 11

Before auscultating the abdomen for the presence of bowel sounds on a patient,the nurse should:

A) warm the end piece of the stethoscope by placing it in warm water.
B) leave the gown on so that the patient does not get chilled during the examination.
C) make sure that the bell side of the stethoscope is turned to the "on" position.
D) check the temperature of the room and offer blankets to the patient if he or she feels cold.

Question 12

The nurse is teaching a class on basic assessment skills.Which of these statements is true regarding the stethoscope and its use?

A) The slope of the earpieces should point posteriorly (toward the occiput).
B) The stethoscope does not magnify sound but does block out extraneous room noise.
C) The fit and quality of the stethoscope are not as important as its ability to magnify sound.
D) The ideal tubing length should be 22 inches to dampen distortion of sound.

Question 13

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

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

Question 14

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

A) Inspection usually yields little information.
B) Inspection takes time and reveals a surprising amount of information.
C) Inspection may be somewhat uncomfortable for the expert practitioner.
D) Inspection requires a quick glance at the patient's body systems before proceeding on with palpation.

Question 15

An examiner is using an ophthalmoscope to examine a patient's eyes.The patient has astigmatism and is nearsighted.The use of which of these techniques would indicate that the examination is being performed correctly?

A) Using the large full circle of light when assessing pupils that are not dilated
B) Rotating the lens selector dial to the black numbers to compensate for astigmatism
C) Using the grid on the lens aperture dial to visualize the external structures of the eye
D) Rotating the lens selector dial to bring the object into focus

Question 16

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

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 17

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

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 so that the patient does not change positions too often.

Question 18

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?

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) Refer the child immediately 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.

Question 19

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

A) Count the patient's respirations.
B) Percuss the thorax bilaterally, noting any differences in percussion tones.
C) Call for a chest x-ray and wait for the results before beginning an assessment.
D) Inspect the thorax for any new masses and bleeding associated with respirations.

Question 20

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

A) palpation.
B) inspection.
C) percussion.
D) auscultation.

Question 21

A 2-year-old child has been brought to the clinic for a well-child check-up.The best way for the nurse to begin the assessment is reflected by which statement?

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 interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.

Question 22

When examining an aging adult,the nurse should use which technique?

A) Avoid touching the patient too much.
B) Attempt to perform the entire physical examination during one visit.
C) Speak loudly and slowly because most aging adults have hearing deficits.
D) Arrange the sequence to allow as few position changes as possible.

Question 23

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

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

Question 24

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

A) "Your atrial dysrhythmias are 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 25

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during 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 26

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

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

Question 27

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?

A) Asking questions enhances the child's autonomy.
B) Asking the child for permission helps to develop a sense of trust.
C) This 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 there is none.

Question 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 nurse do first when beginning the examination?

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 29

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 drum-like quality of the sound across the quadrants.This type of sound indicates:

A) constipation.
B) air-filled areas.
C) the presence of a tumor.
D) the presence of dense organs.

Question 30

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

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 alleviate his anxiety.
C) 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.
D) provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

Question 31

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

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 briefly leave the room when assessing the infant's vital signs.

Question 32

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?

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

Question 33

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

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 34

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

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 there is nonintact skin, excretions containing visible blood, or expected contact with mucous membranes.

Question 35

The nurse is preparing to examine a 4-year-old child.Which action is appropriate for this age group?

A) Explain procedures in detail to alleviate the child's anxiety.
B) Give the child feedback and reassurance during the examination.
C) Do not ask the child to remove his clothes because children at this age are usually very private.
D) Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen.

Question 36

While auscultating heart sounds,the nurse hears a murmur.Which of these should be used to assess this murmur?

A) An electrocardiogram
B) The bell of the stethoscope
C) The diaphragm of the stethoscope
D) Palpation with the palm of the nurse's hand

Question 37

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

A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact.
B) Wash hands before and after every physical patient encounter.
C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.
D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

Question 38

With which of these patients would it be most appropriate for the nurse to use games during the assessment,such as,having the patient "blow out" the light on the penlight?

A) Infant
B) Preschool child
C) School-age child
D) Adolescent

Question 39

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

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

Question 40

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath.How should the nurse proceed with the assessment?

A) Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
B) Obtain a thorough history and physical assessment information from the patient's family member.
C) Perform a complete history and physical assessment immediately to obtain baseline information.
D) Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved.

Question 41

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

A) Start with the thorax, abdomen, and genitalia before examining the head.
B) Avoid talking about the equipment being used because it may increase the child's anxiety.
C) Keep in mind that a child this age will have a sense of modesty.
D) Have the child undress from the waist up.

Question 42

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

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

Question 43

The nurse is preparing to palpate the thorax and abdomen of a patient.Which of these statements describes correct technique for this procedure? Select all that apply.

A) Warm the hands first before touching the patient.
B) For deep palpation, use one long continuous palpation when assessing the liver.
C) Start with light palpation to detect surface characteristics.
D) Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.
E) Identify any tender areas, and palpate them last.
F) Use the palms of the hands to assess temperature of the skin.