Jarvis 8
When performing a physical assessment, what technique should the nurse always perform first?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
B. Inspection Correct
While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
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.
A. Consider this a normal finding. Correct
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. Alcohol-based hand rub should be used 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.
C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. Correct
The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
A. To provide an opportunity for interaction between the patient and the nurse
B. To provide a form for obtaining the patient’s biographic information
C. To document the normal and abnormal findings of a physical assessment
D. To provide a database of subjective information about the patient’s past and current health
D. To provide a database of subjective information about the patient’s past and current health
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
B. Dorsal surface of the hand
C. Ulnar portion of the hand
D. Palmar surface of the hand
B. Dorsal surface of the hand Correct
he nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
A. Used to listen for high-pitched sounds
B. Used to listen for low-pitched sounds
C. Should be lightly held against the person’s skin to block out low-pitched sounds
D. Should be lightly held against the person’s skin to listen for extra heart sounds and murmur
A. Used to listen for high-pitched sounds Correct
Which should the nurse do when preparing to perform a physical examination on an infant?
A. Have the parent remove all clothing except the diaper on a boy. Correct
B. Instruct the parent to feed the infant immediately before the examination.
C. Encourage the infant to suck on a pacifier during abdominal auscultation.
D. Ask the parent to leave the room briefly when assessing the infant’s vital signs.
A. Have the parent remove all clothing except the diaper on a boy. Correct
A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care?
A. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
B. J.M. came into the clinic complaining of having black stools for the past 24 hours.
C. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked.
D. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours.
D. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours.
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
A.
The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next?
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. Correct
D. Check for the presence of pulsations with a stethoscope.
C. Use a Doppler device to check for pulsations over the area. Correct
The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment?
A. Will have no decrease in any of his abilities, including response time.
B. Will have difficulty on tests of remote memory because this ability typically decreases with age.
C. May take a little longer to respond, but his general knowledge and abilities should not have declined.
D. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge.
C. May take a little longer to respond, but his general knowledge and abilities should not have declined. Correct
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response?
A. “Can you point to where it hurts?” Correct
B. “What have you had to eat in the last 24 hours?”
C. “Have you ever had any surgeries on your abdomen?”
D. “We’ll talk more about that later in the interview.”
A. “Can you point to where it hurts?” Correct
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
B. Palpating the kidneys and uterus Correct
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 nurse’s palm of the hand
B. Bell of the stethoscope Correct
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action?
A. Perform a complete mental status examination.
B. Refer him to a psychometrician.
C. Plan to integrate the mental status examination into the history and physical examination.
D. Reassure his wife that memory loss after a physical shock is normal and will soon subside.
A. Perform a complete mental status examination. Correct
In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
A. Patient denies usual childhood illnesses.
B. Patient states he was a “very healthy” child.
C. Patient states his sister had measles, but he didn’t.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
The nurse is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
A. Turgor
B. Texture
C. Density
D. Consistency
C. Density Correct
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.
D. Arrange the sequence of the examination to allow as few position changes as possible.
A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. What is the best description of this patient’s level of consciousness?
A. Lethargic
B. Obtunded
C. Stuporous
D. Semi-coma
A. Lethargic