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NR 509 Week 7 Immersion Physical Assessment Questions-Answers
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NR 509 Week 7 Immersion Physical Assessment Questions-Answers
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When performing a physical assessment, the first technique the nurse will always useB. Inspection
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The
inspection phase:
B. Takes time and reveals a surprising amount of information
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?
B. Dorsal surface of the hand; the skin is thinner on this surface than on the palms
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
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
D. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being
touched.
The nurse would use bimanual palpation technique in which situation?
B. Palpating the kidneys and the uterus
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ___________
of the underlying tissue.
C. Density
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
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
A. Consider this a normal finding
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?
C. Increase the amount of strength used when attempting to percuss over the abdomen
The nurse hears bilateral loud, long and low tones when percussing over the lungs of a 4 year old child. The nurse should
D. Consider this finding as normal for a child this age and proceed with the examination
A patient has suddenly developed shortness of breath and appears to be insignificant respiratory distress. After calling
the position and placing the patient on oxygen, which of these actions is the best for the nurse to take went further
assisting this patient?
B. Bilaterally percuss the thorax, noting any differences in percussion tones
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and
its use?
B. Although the stethoscope does not magnify sound, it does block out extraneous room noise
,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
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
D. Check the temperature of the room and offer blankets to the patient if she or he feels cold.
The nurse will use which technique of assessment to determine the presence of crepitus, swelling and pulsations?
A. Palpation
The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The
otoscope:
D. Directs light into the ear canal and onto the tympanic membrane
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?
D. Rotating the lens selector dial to bring the object into focus
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
C. Use a Doppler device to check for pulsations over the area
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which
statement? The nurse:
D. Organizes the assessment to ensure that the patient does not change positions too often
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
When performing a physical examination, safety must be considered to protect the examiner in the patient against the
spread of the infection. Which of these statements describes the most appropriate action the nurse should take when
performing a physical examination ?
B. Hands are washed before and after every physical patient encounter
The nurses examining a patient lower leg and notices a training ulceration. Which of these actions is most appropriate in
this situation?
C. Washing hands, putting on gloves, and continuing with the examination of the ulceration
During the examination offering some brief teaching about the patient's body or examiners finding is often appropriate.
Which one of these statements by the nurse is most appropriate?
C. Your pulse is 80 beats per minute which is within the normal range
The nurse keeps in mind that the most important reason to share information and to offer brief teaching while
performing be physical examination is to help the:
B. Examiner to build rapport and to increase patient's confidence in him or her
,The nurses examining an infant and prepares to elicit the Moro reflex at which time during the examination?
B. At the end of the examination
When preparing to perform a physical examination of the infant, the nurse should:
A. Have the parent remove all clothing except the diaper on a boy.
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 sleeping
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:
C. Allow the child to keep a security object such as a toy or blanket during the examination
The nurses 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
D. Children at this age like to say no. the examiner should not offer a choice when no choice is available
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 a pen light?
B. Preschool child
The nurse is preparing to examine a 4-year-old child. which action is appropriate for this age group?
B. Give the child feedback and reassurance during the examination
When examining a 16-year-old male teenager, the nurse should:
D. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of
growth and development
When examining an older adult, the nurse should use which technique?
D. The range the sequence of the examination to allow as few position changes as possible
The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is
too:
C. Wash hands before and after contact with each patient
Which of the statements is true regarding the use of standard precautions in the health care setting?
C. Standard precautions are intended for use with all patients, regardless of their risk or presumed infection status
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should
the nurse proceed with the assessment?
D. Body areas appropriate to the problem should be examined and then the assessment completed after the problem
has resolved
When examining an instant, the nurse should examine which area first?
D. Abdomen
, While auscultating heart sounds, the nurse here is a murmur. Which of these instruments should be used to assess this
murmur?
B. Bell of the stethoscope
During an examination of a patient abdomen, the nurse notes that the abdomen is rounded and firm to the touch period
during percussion, the nurse notes a drum like quality of the sounds across the quadrants. this type of sound indicates:
B. Air filled areas
The nurse is preparing to examine a 6-year-old child. which action is the most appropriate?
C. The nurse should keep in mind that a child at this age will have a sense of modesty
During auscultation of a patient's heart sounds, the nurse here's an unfamiliar sound. the nurse should:
D. Ask another nurse to double check the finding
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 before touching be 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 fingertip 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
Answer A,C,D,E
The nurse is performing a general survey period which action is a component of the general survey?
A. Observing the patient's body stature and nutritional status
When measuring a patients wait, the nurse is aware of which of these guidelines?
D. In temp should be made to weigh the patient at approximately the same time of day, if a sequence of weight is
necessary
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mmHg and 138/88 mmHg, with
an average reading of 126/86 mmHg. The nurse knows that this blood pressure falls within which blood pressure
category?
B. Prehypertension
During an examination of a child, the nurse considers that physical growth is the best index of a child's :
A. general Health
A one-month old infant has a head measurement of 34 centimeters and has a chest circumference of 32 centimeters.
Based on the interpretation of these findings, the nurse would:
B. Consider these findings normal for a one-month old infant
The nurse is assessing and 80-year-old male patient. which assessment findings would be considered normal?
C. Presence of kyphosis and flexion in the knees and hips
The nurse should measure rectal temperatures in which of these patients?
C. Comatose adult
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