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NR 509 / NR509 Advanced Physical Assessment
Week 2 Midterm Exam
Questions with Verified Answers - Chamberlain
Consist of 100 multiple choices Questions with Answers
- When performing a physical assessment, the first technique the nurse will always use A. Palpation B. Inspection C. Percussion D. Auscultation Ans>> Inspection
- The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
2 / 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 patient's body systems before proceeding with palpation Ans>> 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? 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. Ans>> 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
4 / tics and to accustom the patient to being touched. Ans>> 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? A. Palpating the thorax of an infant B. Palpating the kidneys and the uterus C. Assessing pulsations and vibrations D. Assessing the presence of tenderness and pain Ans>> 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. A. Turgor B. Texture C. Density D. Consistency Ans>> 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?
5 / A. Percussing once over each area B. Quickly lifting be 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 Ans>> 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 B. Palpate this area for an underlying mass C. Reposition the hands, and attempt to percuss in this area again D. Consider this finding abnormal, and refer the patient for additional treat- ment Ans>> 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? A. Ask the patient to take deep breaths to relax the abdominal musculature B. Consider this finding as normal and proceed with the abdominal assess- ment C. Increase the amount of strength used when attempting to percuss
7 / abdomen. Ans>> 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 A. Palpate over the area for increased pain and tenderness B. Ask the child to take shallow breaths and percuss over the area again C. Immediately refer the child because of an increased amount of air in the lungs D. Consider this finding as normal for a child this age and proceed with the examination Ans>> 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? A. Count the patient's 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
8 / beginning an assessment D. Inspect the thorax for any new masses and bleeding associated with respirations Ans>> 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? 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- Ans>> 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 state- ment is true regarding the diaphragm of the stethoscope? The diaphragm: A. Is used to listen for high-pitched sounds
10 / D. Should be lightly held again the person skin to listen for extra heart sounds and murmurs Ans>> Is used to listen for high-pitched sounds
- 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 she or he 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 she or he feels cold. Ans>> 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 pres- ence of crepitus, swelling and pulsations? A. Palpation B. Inspection C. Percussion D. Auscultation
11 / Ans>> Palpation
- 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 Ans>> 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? 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 to visualize the external structures of the eye D. Rotating the lens selector dial to bring the object into focus Ans>> Rotating the lens selector dial to bring the object into focus
- The nurse is unable to palpate the right radial pulse on a patient.
13 / D. Check for the presence of pulsations with a stethoscope Ans>> 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: A. Performs the examination from the left side of the bed B. Examines the tender of painful areas first to help relieve the patient's 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 Ans>> 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 B. Stay in the room when he undresses in case he needs assistance C. Ask him to change into an examination gown to take off his
14 / undergarments D. Defer measuring vital signs until the end of the examination which allows him time to become comfortable Ans>> Appear unhurried and confident when exam- ining 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? 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 Ans>> 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? A. Washing hands and contacting the physician
16 / D. Washing hands, proceeding with the rest of the physical examination, and then continuing with the examination of the leg ulceration Ans>> 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? 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. I am using my stethoscope to listen for any crackles, wheezes or rubs Ans>> 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 informa- tion 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
17 / D. Patient identify questions about his or her disease and the potential areas of patient education Ans>> Examiner to build rapport and to increase patient's confi- dence in him or her
- The nurses examining an infant and prepares to elicit the Moro reflex at which time during the examination? A. When the infant is sleeping B. At the end of the examination C. Before auscultation of the thorax D. Halfway through the examination Ans>> 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. B. Instructed the parent to feed the infant immediately before the examination C. Encourage the infant to suck on a pacifier during the abdominal examina- tion D. Ask the parents to leave the room briefly when assessing be infants' vital signs Ans>> Have the parent remove all clothing except the diaper on a boy.
19 / 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 Ans>> 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: A. Ask the parent to place the child on the examining table B. Happy parents 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 the interactions on the child, essentially ignoring the parent until the child's trust has been obtained Ans>> 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 A. Asking questions enhances the child autonomy B. Asking the child for permission helps develop a sense of trust
20 / C. This question is inappropriate statement 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 no choice is available Ans>> 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? A. Infant B. Preschool child C. School age child D. Adolescent Ans>> Preschool child
- The nurse is preparing to examine a 4-year-old child. which action is appropriate for this age group? A. Explain the procedures in detail to alleviate the child anxiety B. Give the child feedback and reassurance during the examination C. Do not ask the child to remove his or her clothes because children at this age are usually very private D. Perform an examination of the ear, nose, and throat first, and then
