Deck 8: Assessment Techniques and the Clinical Setting

Question 1

When performing a physical assessment,the technique the nurse will always use first is:
1)palpation.
2)inspection.
3)percussion.
4)auscultation.

Answer 1

2
The assessment of each body system begins with inspection.

Question 2

During the examination,it is often appropriate to offer some brief teaching about the patient's body or one's findings.Which of the following statements by the nurse is most appropriate?
1)"Your hypertension is under control."
2)"You have pitting edema and mild varicosities."
3)"Your pulse is 80 beats per minute.This is within the normal range."
4)"I'm using my stethoscope to listen for any crackles,wheezes,or rubs."

Answer 2

3
Sharing of information builds rapport as long as the patient is able to understand the terminology.

Question 3

A man is at the clinic for a physical examination.He states that he is "very anxious" about the physical exam.What steps can the examiner take to make him more comfortable?
1)Appear unhurried and confident when examining him.
2)Stay in the room when he undresses in case he needs assistance.
3)Ask him to change into an examining gown and take off his undergarments.
4)Defer measuring vital signs until the end of the examination,which allows him.time to become comfortable.

Answer 3

1
Anxiety can be reduced by an examiner who is confident,self-assured,considerate,and unhurried.Familiar and relatively nonthreatening actions,such as measuring the person's vital signs,will gradually accustom the person to the examination.

Question 4

The inspection phase of the physical assessment:
1)yields little information.
2)takes time and reveals a surprising amount of information.
3)may be somewhat uncomfortable for the expert practitioner.
4)requires a quick glance at the patient's body systems before proceeding on with palpation.

Question 5

The nurse is unable to palpate the right radial pulse on a patient.The best action would be to:
1)auscultate over the area with a fetoscope.
2)use a goniometer to measure the pulsations.
3)use a Doppler device to check for pulsations over the area.
4)check for the presence of pulsations with a stethoscope.

Question 6

Before auscultating the abdomen for the presence of bowel sounds on a patient,the nurse will:
1)warm the end piece of the stethoscope by placing it in warm water.
2)leave the gown on so that the patient does not get chilled during the examination.
3)make sure that the bell side of the stethoscope is turned to the "on" position.
4)check the temperature of the room and offer blankets to the patient if he or she feels cold.

Question 7

Which of the following statements is true regarding the otoscope?
1)The otoscope is often used to direct light onto the sinuses.
2)The otoscope uses a short broad speculum to visualize the ear.
3)The otoscope is used to examine the structures of the internal ear.
4)The otoscope directs light into the ear canal and onto the tympanic membrane.

Question 8

The nurse would use bimanual palpation technique in which situation?
1)Palpating the thorax of an infant
2)Palpating the kidneys and uterus
3)Assessing pulsations and vibrations
4)Assessing the presence of tenderness and pain

Question 9

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?
1)Ask the patient to take deep breaths to relax the abdominal musculature
2)Consider this a normal finding and proceed with the abdominal assessment.
3)Increase the amount of strength used when attempting to percuss over the abdomen.
4)Decrease the amount of strength used when attempting to percuss over the abdomen.

Question 10

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

Question 11

The nurse is examining a patient's lower leg and notes a draining ulceration.Which of the following actions is most appropriate in this situation?
1)Wash hands and contact the physician.
2)Continue to examine the ulceration and then wash hands.
3)Wash hands,put on gloves,and continue with the examination of the ulceration.
4)Wash hands,proceed with rest of the physical examination,and then continue with the examination of the leg ulceration.

Question 12

Which of the following techniques uses the sense of touch when assessing a patient?
1)Palpation
2)Inspection
3)Percussion
4)Auscultation

Question 13

The most important reason to share information and offer brief teaching while performing the physical examination is to help:
1)the examiner feel more comfortable and gain control of the situation.
2)build rapport and increase the patient's confidence in the examiner.
3)the patient understand his or her disease process and treatment modalities.
4)the patient identify questions about his or her disease and potential areas of patient education.

Question 14

The nurse is preparing to percuss to assess the underlying:
1)tissue turgor.
2)tissue texture.
3)tissue density.
4)tissue consistency.

Question 15

The nurse is preparing to percuss the thorax of an adult.Which technique is correct?
1)Use the direct percussion technique.
2)Use the indirect percussion technique.
3)Use the ulnar surface of the hand to percuss the thorax.
4)Use the dorsal surface of the hand to percuss the thorax.

Question 16

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress.Which of the following is the best action for the nurse to take?
1)Count the respirations and put a call in to the physician.
2)Percuss the thorax bilaterally,noting any differences in percussion tones.
3)Call for a chest x-ray and wait for the results before beginning an assessment.
4)Inspect the thorax for any new masses and bleeding associated with respirations.

Question 17

Which technique of assessment is used to determine the presence of crepitus,swelling,and pulsations?
1)Palpation
2)Inspection
3)Percussion
4)Auscultation

Question 18

Which statement is true regarding the diaphragm of the stethoscope?
1)Use the diaphragm to listen for high-pitched sounds.
2)Use the diaphragm to listen for low-pitched sounds.
3)Hold the diaphragm lightly against the person's skin to block out low-pitched sounds.
4)Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.

Question 19

The nurse is preparing to assess a patient's abdomen by palpation.How should the nurse proceed?
1)Avoid palpation of reported "tender" areas because this may cause the patient pain.
2)Quickly palpate the area to avoid any discomfort that the patient may experience.
3)Begin the assessment with deep palpation,encouraging the patient to relax and take deep breaths.
4)Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Question 20

When performing a physical examination,safety must be considered to protect the examiner and the patient against the spread of infection.Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?
1)There is no need to wash one's hands after removing gloves,as long as the gloves are still intact.
2)Wash hands at the beginning of the examination and any time that one leaves and re-enters the room.
3)Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.
4)Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

Question 21

With which of the following patients would it be most appropriate to use games during the assessment,such as,having the patient "blow out" the light on the penlight?
1)An infant
2)A preschool child
3)A school-age child
4)An adolescent

Question 22

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.
1.Should be used to detect the shape and consistency of a mass in the axilla
2.Best for evaluating the skin texture over the abdomen.
3.Used to determine the temperature of the patient's skin.
4.Best for detecting vibration over the thorax and abdomen.
The dorsa (backs)of hands and fingers

Question 23

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.
1.Should be used to detect the shape and consistency of a mass in the axilla
2.Best for evaluating the skin texture over the abdomen.
3.Used to determine the temperature of the patient's skin.
4.Best for detecting vibration over the thorax and abdomen.
Fingertips

Question 24

Which of the following statements is true regarding the use of standard precautions in the health care setting?
1)Standard precautions apply to all body fluids,including sweat.
2)Airborne,droplet,and contact transmission-based precautions are included in the use of standard precautions.
3)Standard precautions are intended for use with all patients regardless of their risk or presumed infection status.
4)Standard precautions are to be used only when there is nonintact skin,excretions contain visible blood,or contact with mucous membranes is expected.

Question 25

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath.How should the nurse proceed with the assessment?
1)Have the patient lie down to obtain an accurate cardiac,respiratory,and abdominal assessment.
2)Obtain a thorough history and physical assessment information from the patient's family member.
3)Perform a complete history and physical assessment immediately to obtain baseline information.
4)Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved.

Question 26

When preparing to perform a physical examination on an infant,the examiner should:
1)have the parent remove all clothing except the diaper on a boy.
2)instruct the parent to feed the infant immediately before the exam.
3)encourage the infant to suck on a pacifier during the abdominal exam.
4)ask the parent to briefly leave the room when assessing the infant's vital signs.

Question 27

In infants,the nurse knows to elicit the Moro reflex:
1)when the infant is sleeping.
2)at the end of the examination.
3)before auscultation of the thorax.
4)halfway through the examination.

Question 28

The most important step that the nurse can take to prevent transmission of nosocomial infections in the hospital setting is to:
1)wear protective eye wear at all times.
2)wear gloves during any and all contact with patients.
3)wash hands before and after contact with each patient.
4)clean the stethoscope with an alcohol swab between patients.

Question 29

When examining the aging adult,the nurse should:
1)avoid touching the patient too much.
2)attempt to perform the entire physical during one visit.
3)speak loudly and slowly because most aging adults have hearing deficits.
4)arrange the sequence to allow as few position changes as possible.

Question 30

The nurse is examining a 2-year-old child and asks,"May I listen to your heart now?" Which critique of her technique is most accurate?
1)Asking questions enhances the child's autonomy.
2)Asking the child for permission helps to develop a sense of trust.
3)This is an appropriate statement because children at this age like to have choices.
4)Children at this age like to say "No." The examiner should not offer a choice when there is none.

Question 31

When examining a 16-year-old male teenager,the examiner should:
1)discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness.
2)ask his parent to stay in the room during the history and physical examination to answer any questions and alleviate his anxiety.
3)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.
4)provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

Question 32

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.
1.Should be used to detect the shape and consistency of a mass in the axilla
2.Best for evaluating the skin texture over the abdomen.
3.Used to determine the temperature of the patient's skin.
4.Best for detecting vibration over the thorax and abdomen.
Base of fingers (metacarpophalangeal joints)or ulnar surface of the hand

Question 33

While auscultating heart sounds,the nurse hears a murmur.Which of the following should be used to assess this murmur?
1)An electrocardiogram
2)The bell of the stethoscope
3)The diaphragm of the stethoscope
4)Palpation with the palm of one's hand

Question 34

When examining an infant,the nurse should examine which area first?
1)Ear
2)Nose
3)Throat
4)Abdomen

Question 35

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:
1)constipation.
2)air-filled areas.
3)the presence of a tumor.
4)the presence of dense organs.

Question 36

A 2-year-old child has been brought to the clinic for a well-child check-up.How should the examiner proceed with the assessment?
1)Ask the parent to place the child on the examining table.
2)Have the parent remove all the child's clothing before the examination.
3)Allow the child to keep a security object such as a toy or blanket during the examination.
4)Initially focus interactions on the child,essentially "ignoring" the parent,until the child's trust has been obtained.

Question 37

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.
1.Should be used to detect the shape and consistency of a mass in the axilla
2.Best for evaluating the skin texture over the abdomen.
3.Used to determine the temperature of the patient's skin.
4.Best for detecting vibration over the thorax and abdomen.
A grasping action of the fingers and thumb

Question 38

A 6-month-old infant has been brought to the well-child clinic for a check-up.She is currently sleeping.What should the examiner do first?
1)Auscultate the lungs and heart while the infant is still sleeping.
2)Examine the infant's hips because this procedure is uncomfortable.
3)Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
4)Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.