Chapter 8: Assessment Techniques and the Clinical Setting

Question 1

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

a. palpation.
b. inspection.
c. percussion.
d. auscultation.

Answer 1

b.

Question 2

The inspection phase of the physical assessment:

a. yields little information.
b. takes time and reveals a surprising 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 to palpation.

Answer 2

b.

Question 3

The nurse is assessing a patient’s skin during an office visit. What is the best technique to use to best assess skin temperature?

a. Use the fingertips because they are more sensitive to small changes in skin temperature.
b. Use the dorsal surface of the hand because the skin is thinner there than on the palms.
c. Use the ulnar portion of the hand because of its increased blood supply that enhances sensitivity to temperature.
d. Use the palmar surface of the hand because it is most sensitive to skin temperature variations due to its increased nerve supply.

Answer 3

b.

Question 4

Which of the following techniques involves the use of the sense of touch when assessing a patient?

Answer 4

a.

Question 5

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

a. Avoid palpation of reported “tender” areas because this may cause pain to the patient.
b. Palpate the area quickly to avoid causing any discomfort to the patient.
c. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.
d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Answer 5

d.

Question 6

In which situation would the nurse use bimanual palpation?

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

Answer 6

b.

Question 7

The nurse is preparing to percuss to assess the underlying:

a. tissue turgor.
b. tissue texture.
c. tissue density.
d. tissue consistency.

Answer 7

c.

Question 8

The nurse is preparing to percuss the thorax of an adult. Which of the following techniques is correct?

a. Direct percussion
b. Indirect percussion
c. Using the ulnar surface of the hand
d. Using the dorsal surface of the hand

Answer 8

b.

Question 9

When percussing over the ribs of a patient, the nurse notes a dull sound. The nurse would:

a. consider this a normal finding.
b. palpate this area for an underlying mass.
c. reposition the hands and attempt to percuss over this area again.
d. consider this an abnormal finding and refer the patient for additional investigation.

Answer 9

a.

Question 10

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. Use more force to percuss over the abdomen
d. Use less force to percuss over the abdomen

Answer 10

c.

Question 11

The nurse hears bilateral, louder, longer, and lower-pitched tones when percussing over the lungs of a 4-year-old child. What should the nurse do next?

a. Palpate over the area to identify increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of suspicion 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.

Answer 11

d.

Question 12

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?

a. Count the respirations and call a physician immediately.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest X-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any masses and bleeding associated with respirations.

Answer 12

b.

Question 13

Which of the following statements about the use of the stethoscope is true?

a. The slope of the earpieces should point posteriorly (toward the occiput).
b. The stethoscope does not magnify sound but does block out extraneous noise.
c. The fit and quality of the stethoscope are not as important as its ability to magnify sound.
d. The ideal tubing length should be 56 cm (22 in) to dampen distortion of sound.

Answer 13

b.

Question 14

Which of the following statements about the diaphragm of the stethoscope is true?

a. Use the diaphragm to listen for high-pitched sounds.
b. Use the diaphragm to listen for low-pitched sounds.
c. Hold the diaphragm lightly against the patient’s skin to block out low-pitched sounds.
d. Hold the diaphragm lightly against the patient’s skin to listen for extra heart sounds and murmurs.

Answer 14

a.

Question 15

Before auscultating the patient’s abdomen to detect bowel sounds, the nurse will:

a. warm the end piece of the stethoscope by placing it in warm water.
b. allow the patient to keep the gown on so that he or she does not get chilled during the examination.
c. make sure 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.

Answer 15

d.

Question 16

Which of the following assessment techniques is used to determine the presence of crepitus, swelling, and pulsations?

a. Palpation
b. Inspection
c. Percussion
d. Auscultation

Answer 16

a.

Question 17

Which of the following statements about the otoscope is true?

a. The otoscope is often used to direct light onto the sinuses.
b. The otoscope uses a short broad speculum to visualize the ear.
c. The otoscope is used to examine the structures of the internal ear.
d. The otoscope directs light into the ear canal and onto the tympanic membrane.

Answer 17

d.

Question 18

An examiner is using an ophthalmoscope on a patient who has astigmatism and is nearsighted. Which of the following techniques would indicate that the examination is being performed correctly?

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 adjust 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 the red numbers to adjust for nearsightedness

Answer 18

d.

Question 19

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.

Answer 19

c.

Question 20

During a physical assessment, the examiner should:

a. perform the examination from the left side of the bed.
b. examine tender or painful areas first to help relieve the patient’s anxiety.
c. follow the same examination sequence regardless of the patient’s age or condition.
d. organize the assessment steps so that the patient does not need to change positions too often.

Answer 20

d.

Question 21

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 examiner take to make him feel more comfortable?

a. Appear unhurried and confident during the examination.
b. Stay in the room when the patient undresses in case assistance is needed.
c. Ask the patient to change into an examining gown and then take off his undergarments.
d. Defer measuring vital signs until the end of the examination, which allows the patient time to become comfortable.

Answer 21

a.

Question 22

When performing a physical examination, safety measure must be taken to protect the examiner and the patient against infections. Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?

a. There is no need to wash hands after removing gloves, as long as the gloves are still intact.
b. Wash hands at the beginning of the examination and every time you leave and re-enter the room.
c. Wash hands between examinations of body systems to prevent the spread of pathogens from one part of the body to another.
d. Wear gloves through the entire examination to reassure the patient that you are careful about the spread of infectious diseases.

Answer 22

b.

Question 23

The nurse is examining a patient’s lower leg and notes a draining ulcer. Which of the following actions is most appropriate in this situation?

a. Wash hands first and then contact the physician.
b. Continue to examine the ulcer and then wash hands.
c. Wash hands, put on gloves, and continue with the examination of the ulcer.
d. Wash hands, proceed with rest of the physical examination, and then go on to the examination of the ulcer.

Answer 23

c.

Question 24

During the examination, it is often appropriate to offer some education to the patient about the findings. Which of the following statements by the nurse is most appropriate?

a. “Your hypertension is under control.”
b. “You have pitting edema and mild varicosities.”
c. “Your pulse is 80 beats per minute. This is within the normal range.”
d. “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.”

Answer 24

c.

Question 25

The most important reason to share information and offer brief education while performing the physical examination is to help:

a. the examiner feel more comfortable and gain control of the situation.
b. build rapport and increase the patient’s confidence in the examiner.
c. the patient understand his or her disease process and treatment modalities.
d. the patient identify questions about his or her disease and potential areas of patient education.

Answer 25

b.

Question 26

When examining infants, the nurse will elicit the Moro reflex:

a. when the infant is sleeping.
b. at the end of the examination.
c. before auscultation of the thorax.
d. halfway through the examination.

Answer 26

b.

Question 27

When preparing to perform a physical examination on an infant, the examiner should:

a. have the parent remove all clothing except the diaper on a male infant.
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 briefly leave the room when assessing the infant’s vital signs.

Answer 27

a.

Question 28

A 6-month-old infant has been brought to the well-child clinic for a checkup. She is currently sleeping. What should the examiner do first?

a. Auscultate the lungs and heart while the infant is still sleeping.
b. Examine the infant’s hips when the infant is still asleep because this procedure usually causes discomfort.
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 part of the examination to obtain the most accurate assessment of body systems.

Answer 28

a.

Question 29

A 2-year-old child has been brought to the clinic for a well-child checkup. How should the examiner proceed with the assessment?

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 on your interactions with the child, essentially “ignoring” the parent, until the child’s trust has been obtained.

Answer 29

c.

Question 30

The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which of the following critiques of her technique is most accurate?

a. Asking questions enhances the child’s autonomy.
b. Asking the child’s permission helps create a sense of trust.
c. This is an appropriate approach 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 there is none.

Answer 30

d.

Question 31

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?

a. An infant
b. A preschool child
c. A school-age child
d. An adolescent

Answer 31

b.

Question 32

The nurse is preparing to examine a 4-year-old child. Which of the following actions is appropriate as the first step?

a. Explain procedures in detail to alleviate the child’s anxiety.
b. Give the child feedback and reassurance during the examination.
c. Do not ask the child to remove his clothes because children at this age are usually very private.
d. Perform an examination of the ear, nose, and throat first and then examine the thorax and abdomen.

Answer 32

b.

Question 33

When examining a 16-year-old male teenager, the examiner should:

a. discuss health education 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 taking and physical examination to answer any questions and alleviate his anxiety.
c. talk to him in the same way 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 variations among teenagers in the rates of growth and development.

Answer 33

d.

Question 34

When examining the older adult, the nurse should:

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 older adults have hearing deficits.
d. organize the sequence of steps so that there are as few position changes as possible.

Answer 34

d.

Question 35

The most important step that the nurse can take to prevent transmission of infections in the hospital setting is to:

a. wear protective eye wear at all times.
b. wear gloves during all contact with patients.
c. wash hands before and after contact with each patient.
d. clean the stethoscope with an alcohol swab between patients.

Answer 35

c.

Question 36

Which of the following statements about the application of Routine Practices in the health care setting is true?

a. Routine Practices apply to all instances of contact with body fluids, including sweat.
b. Airborne, droplet, and contact Transmission-Based Precautions are included in Routine Practices.
c. Routine Practices should be followed in the case of all patients regardless of their risk or presumed infection status.
d. Routine Practices are to be followed only when there is non-intact skin, excretions contain visible blood, or contact with mucous membranes is expected.

Answer 36

c.

Question 37

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. Have the patient lie down to make accurate cardiac, respiratory, and abdominal assessments.
b. Obtain a thorough history and physical assessment information from the patient’s family member.
c. Obtain a complete history and perform physical assessment immediately to obtain baseline information.
d. Examine only the body areas related to the problem for which the patient is hospitalized and then do a complete assessment after the problem has been resolved.

Answer 37

d.

Question 38

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

a. Ear
b. Nose
c. Throat
d. Abdomen

Answer 38

d.

Question 39

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

a. An electrocardiogram
b. The bell of the stethoscope
c. The diaphragm of the stethoscope
d. Palpation with the palm of the hand

Answer 39

b.

Question 40

During the examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. Percussion produces a drum-like sound across the quadrants. This type of sound indicates:

a. constipation.
b. air-filled areas.
c. the presence of a tumour.
d. the presence of dense organs.

Answer 40

b.

Question 41

When preparing to examine a 6-year-old child, which action is most appropriate?

a. Start with the thorax, abdomen, and genitalia before examining the head.
b. Avoid talking about the equipment being used because it may increase the child’s anxiety.
c. Keep in mind that a child this age will have a sense of modesty.
d. Have the child undress from the waist up.

Answer 41

c.

Question 42

During auscultation of a patient’s heart, the nurse hears an unfamiliar sound. What should the nurse do next?

a. Document the findings on the patient’s record.
b. Wait 10 minutes and auscultate the heart again.
c. Ask how the patient is feeling.
d. Ask another nurse to double-check the finding.

Answer 42

d.