The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
NURS330 Individual Assessment
Chapter 8 Quiz
Question 1The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
Performs the examination from the left side of the bed
Examines tender or painful areas first to help relieve the patient’s anxiety
Follows the same examination sequence, regardless of the patient’s age or condition
Organizes the assessment to ensure that the patient does not change positions too often
The steps of the assessment should be organized to ensure that the patient does not change positions too often. The examiner will need to perform the examination on both sides of the bed in order to complete a full examination. Tender or painful areas should be assessed last. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference.
Question 2When performing a physical assessment, what technique should the nurse always perform first?
Palpation
Inspection
Percussion
Auscultation
Question 3While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
Consider this a normal finding.
Palpate this area for an underlying mass.
Reposition the hands, and attempt to percuss in this area again.
Consider this finding as abnormal, and refer the patient for additional treatment.
Question 4What is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting?
Wear protective eye wear at all times.
Wear gloves whenever in direct contact with patients.
Wash hands before and after contact with each patient.
Clean the stethoscope with an alcohol swab between patients.
Question 5The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?
Wash hands and then contact the physician.
Continue to examine the ulceration and then wash hands.
Wash hands, put on gloves, and continue with the examination of the ulceration.
Wash hands, proceed with rest of the physical examination, and perform the examination of the leg ulceration last.
Question 6The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
Used to listen for high-pitched sounds
Used to listen for low-pitched sounds
Should be lightly held against the person’s skin to block out low-pitched sounds
Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs
Question 7The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
The child is asked to undress from the waist up.
The thorax, abdomen, and genitalia are examined before the head.
The nurse should keep in mind that a child at this age will have a sense of modesty.
Talking about the equipment being used is avoided because doing so may increase the child’s anxiety.
Question 8The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?
Percussing once over each area
Striking with the fingertip, not the finger pad
Using the wrist to make the strikes, not the arm
Quickly lifting the striking finger after each stroke
Question 9The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?
Palpation
Inspection
Percussion
Auscultation
Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain.
Question 10Which should the nurse do when preparing to perform a physical examination on an infant?
Have the parent remove all clothing except the diaper on a boy.
Instruct the parent to feed the infant immediately before the examination.
Encourage the infant to suck on a pacifier during abdominal auscultation.
Ask the parent to leave the room briefly when assessing the infant’s vital signs.
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