NR 509 week 2. Questions and well
highlighted answers.
When performing a physical assessment, the first technique the nurse will always use
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Correct Answer: B. Inspection
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 Correct
Answer: A. Palpation
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
Correct Answer: C. Density
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 finding as normal 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.
Correct Answer: C. Increase the amount of strength used when attempting to percuss
over the abdomen
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 to 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
Correct Answer: B. although the stethoscope does not magnify sound, it does block out
extraneous room noise
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
Correct Answer: A. Palpation
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
Correct Answer: C. Use a Doppler device to check for pulsations over the area
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 ?
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 spirit 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 disease
Correct Answer: B. Hands are washed before and after every physical patient encounter
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:
A. Examiner feel more comfortable and to gain control of the situation
B. Examiner to build rapport and to increase patient's confidence in him or her
C. Patient understand his or her disease process and treatment modalities
D. Patient identifies questions about his or her disease and the potential areas of patient
education
Correct Answer: B. Examiner to build rapport and to increase patient's confidence in
him or her
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
B. Examine the instance 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
Correct Answer: A. Auscultate the lungs and heart while the infant is sleeping
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?
A. Infant
B. Preschool child
C. School age child
D. Adolescent Correct Answer: B. Preschool child
When examining an older 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. The range the sequence of the examination to allow as few position changes as
possible Correct Answer: D. The range the sequence of the examination to allow as few
position changes as possible
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. Be 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 resolved
Correct Answer: D. Body areas appropriate to the problem should be examined and
then the assessment completed after the problem has resolved
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:
A. Constipation
B. Air filled areas
C. Presence of a tumor
D. Presence of dense organs
Correct Answer: B. Air filled areas
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
Correct Answer: Answer A, C, D, E
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?
A. Normal blood pressure
B. Prehypertension
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: B. Prehypertension
The nurse is assessing and 80-year-old male patient. which assessment findings would
be considered normal?
A. Increase in body weight from his younger years
B. Additional deposits at sat on the thighs and lower legs
C. Presence of kyphosis and flexion in the knees and hips
D. Change and overall body proportion, Including a longer trunk and shorter
extremities
Correct Answer: C. Presence of kyphosis and flexion in the knees and hips
The nurse knows that one advantage of the tympanic membrane thermometer is that:
A. Rapid measurement is useful for uncooperative young children
B. Using the TMT is the most accurate method for measuring body temperature in
newborn infants
C. Measuring temperature using the TMT is inexpensive
D. Studies strongly support the use of TMT in children under the age of 6 years
Correct Answer: A. Rapid measurement is useful for uncooperative young children
When measuring a patient's body temperature, the nurse keeps in mind that the body
temperature is influenced by:
A. Constipation
B. Patients emotional state
C. Diurnal cycle
D. Nocturnal Cycle
Correct Answer: C. Diurnal cycle
When assessing a 75 year old patient who has asthma, the nurse notes that he assumes a
tripod position, leaning forward with arms braced on the chair. on the basis of this
observation, the nurse should:
A. Assume that the patient is eager and interested in participating in the interview
B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting
position
C. Assume that the patient is having difficulty breathing and assist him to a supine
position
D. Recognize that a tripod position is often used when a patient is having respiratory
difficulties Correct Answer: D. Recognize that a tripod position is often used when a
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