Exam (elaborations)
Exam (elaborations) NR 509
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Exam (elaborations) NR 509
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Physical Assessment Practice Questions1. The nurse is assessing a postoperative patient for signs of
hemorrhage. Which adaptation is most indicative of shock?
1. Hyperemia
2. Hypotension
3. Irregular pulse
4. Slow respirations: 2. Hypotension
1. During the compensatory stage of
shock,blood is shunted away from, not
toward, the periphery. Hyperemia is an
increase in blood fl ow to an area where the
overlying skin becomes reddened and
warm.
2. The circulating blood volume is reducedby
25% to 35% during the compensatory
stage of shock and 35% to 50% during the
progressive stage of shock as the
peripheral vessels constrict to increase
blood fl ow to vital organs. This shunting of
blood causes hypotension.
3. With shock, the heart rate increases
(tachycardia); it is not irregular. The heart rate
increases during the compensatory stage of
shock to maintain adequate blood fl ow to
body tissues.
4. During the compensatory stage of
shock,the respiratory rate increases, not
decreases, to maintain adequate
oxygenation of body cells.
2. The nurse is monitoring the vital signs of a group of patients. When
reviewing these results, the nurse must remember that body temperature
usually is at its highest at: 1. 12 AM-2 AM
2. 6 AM-8 AM
3. 4 PM-6 PM
4. 8 PM-10 PM: 4. 8 PM-10 PM
1. The body temperature is on the decline
, Physical Assessment Practice Questions
during this time.
2. The body temperature is just beginning to
risefrom its lowest level, which occurs
between 4 AM and 6 AM.
3. Although the body temperature is rising, it
hasnot reached its peak at this time.
4. Diurnal variations (circadian rhythms)
varythroughout the day with the highest body
temperature usually occurring between
8 PM and
3. When assessing for borborygmi, which physical examination
method should the nurse use?
1. Auscultation
2. Percussion
3. Inspection
4. Palpation: 1. Auscultation
1. Auscultation is the process of listeningto
sounds produced in the body. It is
performed directly by just listening with the
ears or indirectly by using a stethoscope
that amplifi es the sounds and conveys
them to the nurse's ears. Active intestinal
peristalsis causes rumbling, gurgling, and
tinkling abdominal sounds known as bowel
sounds (borborygmi).
2. Percussion may stimulate intestinal
motility,which increases bowel sounds, but it
is not the assessment method used to hear
bowel sounds. Percussion is the act of
striking the body's surface to elicit sounds
that provide information about the size and
shape of internal organs or whether tissue is
air-fi lled, fl uid-fi lled, or solid.
3. Inspection cannot assess bowel
sounds.Inspection uses the naked eye to
perform a visual assessment of the body.
, Physical Assessment Practice Questions
4. Palpation may stimulate intestinal motility,
which increases bowel sounds, but it is not the
assessment method used to hear bowel sounds.
Palpation is the examination of the body using
the sense of touch.
4. The nurse plans to take a patient's radial pulse. Which method of
examination should be used by the nurse?
1. Palpation
2. Inspection
3. Percussion
4. Auscultation: 1. Palpation
1. Palpation, the examination of the
bodyusing the sense of touch, is used to obtain
the heart rate at a pulse site. When measuring
a pulse, an artery is compressed slightly by the
fi ngers so that the pulsating artery is held
between the fi ngers and a bone or fi rm
structure.
2. A pulse is not measured by using the
senseof sight. Inspection uses the naked eye to
perform a visual assessment of the body.
3. Percussion cannot measure a pulse.
Percussionis the act of striking the body's
surface to elicit sounds that provide information
about the size and shape of internal organs or
whether tissue is air-fi lled, fl uid-fi lled, or solid.
4. Auscultation is used to obtain an apical,
notradial, pulse. Auscultation is the process of
listening to sounds produced in the body. It is
performed directly by just listening with the ears
or indirectly by using a stethoscope that amplifi
es the sounds and conveys them to the nurse's
ears.
5. Which nursing action is common to all
instruments when taking a temperature?
1. Identify that the reading is below 96°F before insertion
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