Chapter 6 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 6

Question 1

Type: HOTSPOT

The nursing instructor is demonstrating, to a group of nursing students, the proper technique for assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate proper technique?

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Standard Text: Select the correct area on the image.

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Correct Answer:

Rationale : Fremitus, or vibration, is best assessed using the metacarpophalangeal joints, at the base of the fingers on the ulnar surface of the hand.

Global Rationale:

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 2

Type: MCSA

The nurse is preparing to assess the thorax of an infant using the assessment technique of direct percussion. To correctly perform this assessment the nurse will use the:

1. hyperextended middle finger of the nondominant hand.

2. closed fist of dominant hand.

3. palm of the nondominant hand.

4. fingertips of the dominant hand.

Correct Answer: 4

Rationale 1: Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor.

Rationale 2: Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand.

Rationale 3: The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion.

Rationale 4: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult client.

Global Rationale: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an adult client. Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 3

Type: MCSA

During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which of the following would be the best action for the nurse to take next?

1. Document this as abnormal.

2. Wet the chest hair before auscultating the chest.

3. Place the diaphragm on top of the clients shirt.

4. Switch from the diaphragm to the bell.

Correct Answer: 2

Rationale 1: The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal.

Rationale 2: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the clients chest before auscultation.

Rationale 3: Auscultating lung sounds over the clients clothing will increase rather than decrease friction sounds.

Rationale 4: Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them wont make a difference.

Global Rationale: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the clients chest before auscultation. The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Auscultation of lung sounds over the clients clothing will increase rather than decrease friction sounds. Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them wont make a difference.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 4

Type: MCSA

The nursing instructor is observing a student nurse who is performing abdominal palpation on an adult client. In order to assess organs that lie deep within the abdominal cavity (e.g., kidneys, spleen), the student nurse should press on the clients abdomen using which of the following techniques?

1. Downward pressure of 12 cm using the finger pads

2. Side to side pressure of 1 cm using the finger pads

3. Downward pressure of 24 cm using the palmar surface of the fingers

4. Light pressure using the base of the fingers (metacarpophalangeal joints)

Correct Answer: 3

Rationale 1: Downward depression of 12 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen.

Rationale 2: Side-to-side palpation of 1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node).

Rationale 3: Deep palpation of 24 cm (3/41 inches) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward.

Rationale 4: Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

Global Rationale: Deep palpation of 24 cm (3/41 inches) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Downward depression of 12 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Side-to-side palpation of 1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 5

Type: MCSA

The nurse is preparing to assess a clients abdomen. Which of the following sequences will the nurse use to assess this body area?

1. Percussion, Palpation, Auscultation, Inspection

2. Auscultation, Inspection, Palpation, Percussion

3. Inspection, Palpation, Percussion, Auscultation

4. Inspection, Auscultation, Percussion, Palpation

Correct Answer: 4

Rationale 1: Assessement always begins with inspection. Percussing and palpating the abdomen before auscultating could alter the natural sounds of the abdomen.

Rationale 2: Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation.

Rationale 3: Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen.

Rationale 4: The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen.

Global Rationale: The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen. Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation, then percussion, and finally palpation. Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 6

Type: MCSA

The nurse is inspecting a clients chest and upper extremities. Which of the following would be the appropriate method for the nurse to assess these body areas?

1. Examine the right arm, the chest, and then the left arm.

2. Examine the left arm, the chest, and then the right arm.

3. Examine the left arm, the right arm, and then the chest.

4. Examine the chest and examine the arms at the conclusion of the exam as the client is re-dressing.

Correct Answer: 3

Rationale 1: The nurse should compare the left and right arms before moving to the chest.

Rationale 2: The nurse should compare the left and right arms before moving to the chest.

Rationale 3: Inspection begins with a survey of the clients appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest.

Rationale 4: The nurse should give the client privacy at the conclusion of the physical assessment to re-dress.

Global Rationale: Inspection begins with a survey of the clients appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. The nurse should give the client privacy at the conclusion of the physical assessment to re-dress.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 7

Type: MCSA

A client has a reddened area on the left forearm. Which of the following assessment techniques should the nurse use to assess this area?

1. Percussion

2. Light palpation

3. Moderate palpation

4. Deep palpation

Correct Answer: 2

Rationale 1: Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid.

Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.

Rationale 3: Moderate palpation is used to assess most of the other structures of the body.

Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity.

Global Rationale: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Moderate palpation is used to assess most of the other structures of the body. Deep palpation is used to assess an organ that lies deep within a body cavity.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 8

Type: MCSA

While auscultating a clients lungs, the nurse identifies more than one sound. Which of the following should the nurse do?

1. Obtain a stethoscope with longer tubing.

2. Ask another nurse to listen to the lung sounds.

3. Hold the stethoscope tubing while listening to the lung sounds.

4. Close the eyes and focus on one sound at a time.

Correct Answer: 4

Rationale 1: Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds.

Rationale 2: Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard.

Rationale 3: Touching the stethoscope tubing can cause additional sounds and should be avoided.

Rationale 4: Closing the eyes and concentrating on each sound may help the nurse focus on the sound.

Global Rationale: Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Touching the stethoscope tubing can cause additional sounds and should be avoided.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 9

Type: MCSA

The nurse is assessing a clients right lower extremity and during inspection notes an area of redness. In order to assess the temperature of the clients skin, the nurse should use which part of the hand?

1. Fingertips

2. Metacarpophalgeal joints

3. Dorsal surface

4. Ulnar surface

Correct Answer: 3

Rationale 1: The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus.

Rationale 2: The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus.

Rationale 3: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature.

Rationale 4: The ulnar surface of the hand is also used to assess for fremitus.

Global Rationale: The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. The ulnar surface of the hand is also used to assess for fremitus.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 10

Type: MCSA

The nurse is preparing to percuss the lower lobes of a clients lungs. The percussion technique appropriate for this body area would be:

1. direct percussion.

2. blunt percussion.

3. indirect percussion.

4. any of the percussion techniques.

Correct Answer: 3

Rationale 1: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult.

Rationale 2: Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow.

Rationale 3: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used.

Rationale 4: In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion.

Global Rationale: Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to examine the thorax of an infant and to assess the sinuses of an adult. Blunt percussion involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand. A closed fist of the dominant hand is used to deliver the blow. This method is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. In order to gain accurate objective information, it is important for the nurse to choose the proper assessment technique, which in this situation is indirect percussion.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.1: Describe the four basic techniques used by the professional nurse when performing physical assessment.

Question 11

Type: MCMA

The nurse is teaching a group of health assistants about the stethoscope. Which of the following statements about the stethoscope will the nurse include in this teaching session?

Standard Text: Select all that apply.

1. The stethoscope works by blocking out environmental sounds.

2. Short tubing provides the listener with the most accurate sounds.

3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds.

4. Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection.

5. The binaurals should fit snugly in the ears.

Correct Answer: 1,2,5

Rationale 1: The stethoscope works by blocking out environmental sounds. The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body.

Rationale 2: Short tubing provides the listener with the most accurate sounds. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound.

Rationale 3: The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds.

Rationale 4: Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection. The stethoscope should be cleaned after examining a client to prevent the spread of infection.

Rationale 5: The binaurals should fit snugly in the ears. The binaurals should fit snugly yet comfortably in the ears.

Global Rationale: The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. The binaurals should fit snugly yet comfortably in the ears. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. The stethoscope should be cleaned after examining a client to prevent the spread of infection.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.2: Explain the purpose of equipment required to perform physical assessment.

Question 12

Type: MCMA

The nurse uses the otoscope in the physical assessment of a client. The nurse understands that this instrument is used to:

Standard Text: Select all that apply.

1. Inspect the nose.

2. Funnel light into the ear canal.

3. Inspect the internal structures of the eye.

4. Assess pulses that are not palpable.

5. Detect fungal infections of the skin.

Correct Answer: 1,2

Rationale 1: Inspect the nose. The otoscope can be used to inspect the nose, by inserting a wide speculum into the clients naris.

Rationale 2: Funnel light into the ear canal. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself.

Rationale 3: Inspect the internal structures of the eye. The ophthalmoscope is used to inspect the internal structure of the eye.

Rationale 4: Assess pulses that are not palpable. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate.

Rationale 5: Detect fungal infections of the skin. A Woods lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection.

Global Rationale: The otoscope can be used to inspect the nose, by inserting a wide speculum into the clients naris. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. The ophthalmoscope is used to inspect the internal structure of the eye. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. A Woods lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete physical assessment.

Question 13

Type: MCSA

The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which of the following colors is visualized through the red-free filter of the ophthalmoscope?

1. Green

2. Black

3. Red

4. Yellow

Correct Answer: 2

Rationale 1: The color green is not an expected finding of fundoscopic examination of the eye.

Rationale 2: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black.

Rationale 3: The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding.

Rationale 4: Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope.

Global Rationale: The red-free filter is used to examine the optic disc for hemorrhage. This filter shines a green beam into the eye and if hemorrhage is present, the disc will appear black. The color green is not an expected finding of fundoscopic examination of the eye. The color red is observed as the red reflex; light reflecting off the retina when a bright white light is shined through the pupil. This is a normal finding. Yellow is the color of a normal optic disc. This is elicited using the bright white light of the ophthalmoscope.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete physical assessment.

Question 14

Type: HOTSPOT

The nursing instructor is teaching a group of nursing students the correct assessment of normal heart sounds. Draw an arrow on the part of the stethoscope that should be used by the nursing student to auscultate normal heart sounds.

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Standard Text: Select the correct area on the image.

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Correct Answer:

Rationale :

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.2: Explain the purpose of equipment required to perform a complete physical assessment.

Question 15

Type: MCSA

The nurse is about to perform a physical assessment on an adult client. Before beginning this phase of the clients health assessment, the nurse should first:

1. Provide a gown for the client to change into.

2. Explain to the client what will happen during the examination.

3. Obtain a written consent.

4. Wash hands in the presence of the client.

Correct Answer: 2

Rationale 1: The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing.

Rationale 2: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a clients anxiety and enlists the clients cooperation with the assessment.

Rationale 3: Obtaining a written consent is not necessary, unless an invasive procedure will be performed.

Rationale 4: Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given and again at the completion of the physical assessment.

Global Rationale: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a clients anxiety and enlists the clients cooperation with the assessment. The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing. Obtaining a written consent is not necessary, unless an invasive procedure will be performed. Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment.

Question 16

Type: MCSA

The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. The nurse should use which of the following techniques to put the client at ease when assessing the clients abdomen?

1. Palpate known painful areas first.

2. Touch each area lightly before applying deeper palpation.

3. Perform the exam as quickly as possible.

4. Refrain from conversation during the assessment.

Correct Answer: 2

Rationale 1: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense.

Rationale 2: Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction.

Rationale 3: Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction.

Rationale 4: The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the clients health.

Global Rationale: Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. The nurse should proceed slowly, using smooth, deliberate movements during the exam. The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the clients health.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment.

Question 17

Type: MCSA

The nurse is assessing an adult client when suddenly the client refuses to continue the examination. What is the nurses next step?

1. Give the client a short break and then resume the assessment.

2. Document what was done and what was refused.

3. Summon another nurse to the room to serve as a witness.

4. Enlist the assistance of the clients family to encourage the rest of the assessment.

Correct Answer: 2

Rationale 1: The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion.

Rationale 2: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused.

Rationale 3: It is not necessary for another nurse to witness a clients refusal of care. The nurse should document what was done and what the client refused.

Rationale 4: Allowing a family member to be present during the assessment may be helpful, but the clients wishes (refusal) must be respected.

Global Rationale: The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. It is not necessary for another nurse to witness a clients refusal of care. The nurse should document what was done and what the client refused. Allowing a family member to be present during the assessment may be helpful, but the clients wishes (refusal) must be respected.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment.

Question 18

Type: MCMA

The nurse is preparing to perform a complete health assessment on a client. Which of the following activities should the nurse perform just prior to this examination?

Standard Text: Select all that apply.

1. Put on nonsterile gloves.

2. Provide an opportunity for the client to void.

3. Wash hands in the presence of the client.

4. Turn on soft music to relax the client.

5. Lower the lights in the room to prevent glare.

Correct Answer: 2,3

Rationale 1: Put on nonsterile gloves. Gloves are needed only if the nurse may come into contact with the clients blood or body fluids, such as during the assessment of the genitalia or anus.

Rationale 2: Provide an opportunity for the client to void. The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs.

Rationale 3: Wash hands in the presence of the client. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the clients safety and also protects the nurse.

Rationale 4: Turn on soft music to relax the client. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics.

Rationale 5: Lower the lights in the room to prevent glare. The room should be brightly lit to facilitate good visibility.

Global Rationale: The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the clients safety and also protects the nurse. Gloves are needed only if the nurse may come into contact with the clients blood or body fluids, such as during the assessment of the genitalia or anus. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. The room should be brightly lit to facilitate good visibility.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.3: Describe client safety and comfort measures to be considered when performing physical assessment.

Question 19

Type: MCSA

The nurse is assessing a client for hepatomegaly by percussing over the liver. The nurse would expect to hear which of the following sounds when percussing the liver?

1. Loud, low-pitched

2. Soft, high-pitched

3. Drum-like

4. Abnormally loud

Correct Answer: 2

Rationale 1: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines.

Rationale 2: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver.

Rationale 3: Resonance is a loud, low-pitched tone of normal findings over the lungs.

Rationale 4: Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.

Global Rationale: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Resonance is a loud, low-pitched tone of normal findings over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 20

Type: MCSA

A client is brought to the emergency department by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which of the following findings would indicate, to the nurse, the need for a more detailed neurological assessment of this client?

1. Asymmetry of the clients smile

2. Grimacing with movement

3. Talking in a loud voice

4. Inability to follow directions

Correct Answer: 1

Rationale 1: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves.

Rationale 2: Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem.

Rationale 3: Talking in a loud voice may cue the nurse that the client has hearing loss.

Rationale 4: The clients inability to follow directions may also be the result of a hearing loss.

Global Rationale: Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Talking in a loud voice may cue the nurse that the client has hearing loss. The clients inability to follow directions may also be the result of a hearing loss.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 21

Type: MCSA

The nurse is performing an abdominal assessment and has just completed inspection. Which of the following techniques would the nurse correctly choose to use next in this assessment?

1. Percussion

2. Palpation

3. Transillumination

4. Auscultation

Correct Answer: 4

Rationale 1: Percussing before auscultating the abdomen may alter the natural sounds of the abdomen.

Rationale 2: Palpation prior to auscultation of the abdomen could alter the natural sounds; therefore auscultation is performed immediately following inspection.

Rationale 3: Transillumination of the abdomen is not part of the abdominal assessment.

Rationale 4: Auscultation of the abdomen is the assessment technique that follows inspection. It is important to listen before touching to avoid altering a clients natural abdominal sounds.

Global Rationale: Auscultation of the abdomen is the assessment technique that follows inspection. It is important to listen before touching to avoid altering a clients natural abdominal sounds. Percussing before auscultating the abdomen may alter the natural sounds of the abdomen. Palpation prior to auscultation of the abdomen could alter the natural sounds, therefore auscultation is performed immediately following inspection. Transillumination of the abdomen is not part of the abdominal assessment

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 22

Type: MCSA

The nurse is using a Doppler ultrasonic stethoscope to assess a clients pulse in the lower extremity and is unable to locate the pulse. What is the nurses next action?

1. Check the pressure applied to the probe.

2. Add more gel to the end of the probe.

3. Immediately inform the healthcare provider.

4. Send the equipment for repair.

Correct Answer: 1

Rationale 1: Heavy pressure to the probe should be avoided because it may impede blood flowthe probe should be placed gently against the clients skin, over the artery to be auscultated.

Rationale 2: A small amount of gel is applied to the end of the Doppler probe to eliminate interference.

Rationale 3: Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly.

Rationale 4: Sending the equipment for repair is premature at this time.

Global Rationale: Heavy pressure to the probe should be avoided because it may impede blood flowthe probe should be placed gently against the clients skin, over the artery to be auscultated. A small amount of gel is applied to the end of the Doppler probe to eliminate interference. Informing the healthcare provider may be premature until it is determined that the Doppler probe is being used correctly. Sending the equipment for repair is premature at this time.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 23

Type: MCSA

A client has a visible pulsation in the middle of his abdomen. The assessment technique the nurse should use to assess this pulsation is:

1. Percussion.

2. Light palpation.

3. Moderate palpation.

4. Deep palpation.

Correct Answer:

Rationale 1: Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid.

Rationale 2: Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin.

Rationale 3: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present.

Rationale 4: Deep palpation is used to assess an organ that lies deep within a body cavity.

Global Rationale: With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. Deep palpation is used to assess an organ that lies deep within a body cavity.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 24

Type: MCSA

The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which of the following should the nurse do when palpating the abdomen of this client?

1. Assess the painful area first using moderate palpation.

2. Assess the painful area last using deep palpation.

3. Assess the painful area last using light palpation.

4. Assess the painful area first using deep palpation.

Correct Answer: 2

Rationale 1: Painful areas are not palpated first.

Rationale 2: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation.

Rationale 3: Light palpation is used to evaluate surface characteristics, not the structures of the abdomen.

Rationale 4: While deep palpation is the appropriate technique, the painful area is examined last.

Global Rationale: Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. Painful areas are not palpated first. Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. While deep palpation is the appropriate technique, the painful area is examined last.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 25

Type: MCSA

While percussing a clients lung area the nurse notes a flat tone. This tone would indicate:

1. The nurse is percussing over a bone.

2. A normal finding.

3. The lungs are solidified.

4. Air is trapped in the lungs.

Correct Answer: 1

Rationale 1: Flat tones are high-pitched, soft tones of short duration and are the result of percussion over solid tissue such as muscle or bone.

Rationale 2: Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance.

Rationale 3: Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration.

Rationale 4: Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance.

Global Rationale: Flat tones are high-pitched, soft tones of short duration are the result of percussion over solid tissue such as muscle or bone. Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. Solidified areas of the lung will produce dullness on percussion, a high-pitched soft tone of short duration. Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 26

Type: MCSA

The nurse is unable to palpate a clients pedal pulses. Which of the following items will the nurse use to help locate this clients pedal pulses?

1. Stethoscope

2. Doppler

3. Transilluminator

4. Goniometer

Correct Answer: 2

Rationale 1: A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds.

Rationale 2: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses.

Rationale 3: A transilluminator detects blood, fluid, or masses in body cavities.

Rationale 4: A Goniometer is used to measure the degree of joint flexion and extension.

Global Rationale: The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. A transilluminator detects blood, fluid, or masses in body cavities. A goniometer is used to measure the degree of joint flexion and extension.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 27

Type: MCSA

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. What is the nurses next step?

1. Inform the client of the abnormality.

2. Stop the assessment and refer the client to the healthcare provider immediately.

3. Bring in another examiner to assess the finding.

4. Document the finding and reassess at the clients next visit.

Correct Answer: 3

Rationale 1: When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding.

Rationale 2: Informing the client of the abnormality may cause the client undue anxiety, as the finding may be a normal variant.

Rationale 3: The nurse needs to complete the assessment before deciding on the urgency of referral to the health care provider, and this includes having a colleague assess the nurses unfamiliar finding.

Rationale 4: The finding should be investigated at this visit, first by asking another examiner to assess the concern.

Global Rationale: When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Informing the client of the abnormality may cause the client undue anxiety, as the finding may be a normal variant. The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurses unfamiliar finding. The finding should be investigated at this visit, first by asking another examiner to assess the concern.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 28

Type: MCSA

The nurse is preparing to examine several clients in the clinic setting. Which of the following clients would need the greatest degree of special consideration during a physical examination?

1. 59-year old with flu symptoms

2. 3-year-old child in for a well check-up

3. 17-year old who complains of fatigue

4. 68-year old with chronic lung disease

Correct Answer: 4

Rationale 1: A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease.

Rationale 2: Assessment approaches and techniques may vary for children, but a 3-year old is not considered at the same risk potential as a client with a chronic respiratory illness.

Rationale 3: Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen.

Rationale 4: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion.

Global Rationale: Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease.
Assessment approaches and techniques may vary for children, but a 3-year old is not considered at the same risk potential as a client with a chronic respiratory illness. Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6.4: Apply critical thinking when using the four basic techniques of physical assessment.

Question 29

Type: MCMA

The nurse is preparing to assess an adult client who presents to the emergency room after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which of the following should the nurse incorporate into the physical assessment of this client?

Standard Text: Select all that apply.

1. Wash hands in the presence of the client.

2. Put on nonsterile gloves to examine the client.

3. Ensure that the client has an empty bladder before beginning the physical assessment.

4. Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.

5. Assess only the left lower extremity since this is the injured body part.

Correct Answer: 1,2

Rationale 1: Wash hands in the presence of the client. The nurse should always perform handwashing prior to physical contact with a client.

Rationale 2: Put on nonsterile gloves to examine the client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens.

Rationale 3: Ensure that the client has an empty bladder before beginning the physical assessment. When the clients abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation.

Rationale 4: Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a clients anxiety.

Rationale 5: Assess only the left lower extremity since this is the injured body part. The nurse should always do a comparison of both sides of the body.

Global Rationale: The nurse should always perform handwashing prior to physical contact with a client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens. When the clients abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a clients anxiety. The nurse should always do a comparison of both sides of the body.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.5: Apply the principles of Standard Precautions in practice.

Question 30

Type: MCSA

A senior nursing student is working in an elementary school with the school nurse. The student cares for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which action by the nursing student would require immediate intervention by the school nurse?

1. The student nurse puts on nonsterile gloves prior to assessing the childs injuries.

2. The student nurse disposes of blood-soaked gauze in the office trash bin.

3. The student nurse performs handwashing before touching the child.

4. The student nurse asks the child permission to assess the injuries.

Correct Answer: 2

Rationale 1: The use of nonsterile gloves protects the student nurse from direct contact with the childs blood.

Rationale 2: The student nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin.

Rationale 3: Handwashing should be performed before and after client care.

Rationale 4: Asking permission to assess the childs injuries gains the childs attention and cooperation.

Global Rationale: The student nurse should dispose of waste soiled with blood and/or body fluids in a biohazard bin, not the office trash bin. The use of nonsterile gloves protects the student nurse from direct contact with the childs blood. Handwashing should be performed before and after client care. Asking permission to assess the childs injuries gains the childs attention and cooperation.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6.5: Apply the principles of Standard Precautions in practice.

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