Chapter 8: Assessment Techniques & Safety in the Clinical Setting (Practice Questions)

Question 1

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

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

Answer 1

b. Inspection.

Question 2

The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:

a. Usually 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 patients body systems before proceeding with palpation.

Answer 2

b. Takes time and reveals a surprising amount of information.

Question 3

The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature?

a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

Answer 3

b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.

Question 4

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

Answer 4

a. Palpation

Question 5

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

a. Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain.
b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may
experience.
c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths.
d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

Answer 5

d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

Question 6

The nurse would use bimanual palpation technique in which situation?

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. Palpating the kidneys and uterus

Question 7

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

Answer 7

c. Density

Question 8

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
b. Quickly lifting the striking finger after each stroke
c. Striking with the fingertip, not the finger pad
d. Using the wrist to make the strikes, not the arm

Answer 8

a. Percussing once over each area

Question 9

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:

a. Consider this a normal finding.
b. Palpate this area for an underlying mass.
c. Reposition the hands, and attempt to percuss in this area again.
d. Consider this finding as abnormal, and refer the patient for additional treatment.

Answer 9

a. Consider this a normal finding.

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 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.

Answer 10

c. Increase the amount of strength used when attempting to percuss over the abdomen.

Question 11

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

a. Count the patients respirations.
b. Bilaterally percuss the thorax, noting any differences in percussion tones.
c. Call for a chest x-ray study, and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.

Answer 11

b. Bilaterally percuss the thorax, noting any differences in percussion tones.

Question 12

The nurse is teaching a class on basic assessment skills. Which of these statements istrue regarding the stethoscope and its use?

a. Slope of the earpieces should point posteriorly (toward the 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.

Answer 12

b. Although the stethoscope does not magnify sound, it does block out extraneous room noise.

Question 13

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.
b. Is used to listen for low-pitched sounds.
c. Should be lightly held against the persons skin to block out low-pitched sounds.
d. Should be lightly held against the persons skin to listen for extra heart sounds and murmurs.

Answer 13

a. Is used to listen for high-pitched sounds.

Question 14

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:

a. Warm the endpiece of the stethoscope by placing it in warm water.
b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination.
c. Ensure 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 14

d. Check the temperature of the room, and offer blankets to the patient if he or she feels cold.

Question 15

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

Answer 15

a. Palpation

Question 16

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:

a. Is often used to direct light onto the sinuses.
b. Uses a short, broad speculum to help visualize the ear.
c. Is used to examine the structures of the internal ear.
d. Directs light into the ear canal and onto the tympanic membrane.

Answer 16

d. Directs light into the ear canal and onto the tympanic membrane.

Question 17

An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed?

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 compensate 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 bring the object into focus

Answer 17

d. Rotating the lens selector dial to bring the object into focus

Question 18

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 18

c. Use a Doppler device to check for pulsations over the area.

Question 19

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

a. Performs the examination from the left side of the bed.
b. Examines tender or painful areas first to help relieve the patients anxiety.
c. Follows the same examination sequence, regardless of the patients age or condition.
d. Organizes the assessment to ensure that the patient does not change positions too often.

Answer 19

d. Organizes the assessment to ensure that the patient does not change positions too often.

Question 20

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.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his undergarments.
d. Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

Answer 20

a. Appear unhurried and confident when examining him.

Question 21

When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?

a. Washing ones 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 spread of bacteria from one part of the body to another.

Answer 21

b. Hands are washed before and after every physical patient encounter.

Question 22

The nurse is examining a patients lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?

a. Washing hands, and contacting the physician
b. Continuing to examine the ulceration, and then washing hands
c. Washing hands, putting on gloves, and continuing with the examination of the ulceration
d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration

Answer 22

c. Washing hands, putting on gloves, and continuing with the examination of the ulceration

Question 23

During the examination, offering some brief teaching about the patients body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate?

a. Your atrial dysrhythmias are under control.
b. You have pitting edema and mild varicosities.
c. Your pulse is 80 beats per minute, which is within the normal range.
d. Im using my stethoscope to listen for any crackles, wheezes, or rubs.

Answer 23

c. Your pulse is 80 beats per minute, which is within the normal range.

Question 24

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the 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 the patients confidence in him or her.
c. Patient understand his or her disease process and treatment modalities.
d. Patient identify questions about his or her disease and the potential areas of patient education.

Answer 24

b. Examiner to build rapport and to increase the patients confidence in him or her.

Question 25

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. Arrange the sequence of the examination to allow as few position changes as possible.

Answer 25

d. Arrange the sequence of the examination to allow as few position changes as possible.

Question 26

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

a. Wear protective eye wear at all times.
b. Wear gloves during any and 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 26

c. Wash hands before and after contact with each patient.

Question 27

Which of these statements is true regarding the use of Standard Precautions in the health care setting?

a. Standard Precautions apply to all body fluids, including sweat.
b. Use alcohol-based hand rub if hands are visibly dirty.
c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

Answer 27

c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.

Question 28

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. The 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 patients 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.

Answer 28

d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.

Question 29

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

a. Electrocardiogram
b. Bell of the stethoscope
c. Diaphragm of the stethoscope
d. Palpation with the nurses palm of the hand

Answer 29

b. Bell of the stethoscope

Question 30

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 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.

Answer 30

b. Air-filled areas.

Question 31

During auscultation of a patients heart sounds, the nurse hears an unfamiliar sound. The nurse should:

a. Document the findings in the patients record.
b. Wait 10 minutes, and auscultate the sound again.
c. Ask the patient how he or she is feeling.
d. Ask another nurse to double check the finding.

Answer 31

c. Ask the patient how he or she is feeling.

Question 32

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 first before touching the 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 fingertips 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 32

a. Warm the hands first before touching the patient.
c. Start with light palpation to detect surface characteristics.
d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.
e. Identify any tender areas, and palpate them last.