Deck 9: Assessment Techniques and the Clinical Setting

Question 1

When percussing over the liver of a patient, the nurse observes 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.

Answer 1

Consider this a normal finding.

Question 2

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

A)Usually yields little information.
B)Takes time and reveals a significant 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.

Answer 2

Takes time and reveals a significant amount of information.

Question 3

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?

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, not the arm, to make the strikes

Answer 3

Percussing once over each area

Question 4

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

A)Slope of the earpieces should point posteriorly (toward the occiput).
B)Although the stethoscope does not magnify sound, it does block out extraneous room noise.
C)Fit and quality of the stethoscope are not as important as its ability to magnify sound.
D)Ideal tubing length should be 22 inches to dampen the distortion of sound.

Question 5

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 6

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

Question 7

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 8

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 9

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

A)Turgor
B)Texture
C)Density
D)Consistency

Question 10

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?

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 11

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 12

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

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.

Question 13

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

A)Warm the endpiece of the stethoscope by placing it in warm water.
B)Leave the gown on the patient to ensure that he or she does not get chilled during the examination.
C)Ensure 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 14

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?

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 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 correctly performed?

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

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 to ensure that the patient does not change positions too often.

Question 17

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 18

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

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.

Question 19

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

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

Question 20

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 lightly held against the person's skin to block out low-pitched sounds.
D)Should be lightly held against the person's skin to listen for extra heart sounds and murmurs.

Question 21

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 22

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?

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 23

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

Question 24

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:

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 25

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)Washing hands and then 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 26

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:

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 27

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)The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
B)A thorough history and physical assessment information should be obtained from the patient's family member.
C)A complete history and physical assessment should be immediately performed to obtain baseline information.
D)Body areas appropriate to the problem should be examined and then the assessment completed after the problem has been resolved.

Question 28

The most important step that the nurse can take to prevent the 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 29

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 30

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

A)Explaining the procedures in detail to alleviate the child's anxiety
B)Giving the child feedback and reassurance during the examination
C)Not asking the child to remove his or her clothes because children at this age are usually very private
D)Performing examination of the ear, nose, and throat first and then examining the thorax and abdomen

Question 31

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 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 32

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)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 33

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

Question 34

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

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 35

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

A)Avoiding touching the patient too much
B)Attempting to perform the entire physical examination during one visit
C)Speaking loudly and slowly because most aging adults have hearing deficits
D)Arranging the sequence of the examination to allow as few position changes as possible

Question 36

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

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

Question 37

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

A)Electrocardiography
B)Bell of the stethoscope
C)Diaphragm of the stethoscope
D)Palpation with the nurse's palm of the hand

Question 38

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)"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 39

During 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)Constipation
B)Air-filled areas
C)Presence of a tumour
D)Presence of dense organs

Question 40

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 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 41

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

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 42

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound.The nurse should:

A)Document the findings in the patient's record.
B)Wait 10 minutes, and auscultate the sound again.
C)Ask the patient how he or she 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 the 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.

Question 44

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

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