Health Assessment and Physical Examination

1.While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during inspiration and expiration. These sounds can best be described as which of the following?

a.
Crackles
b.
Rhonchi
c.
Wheezes
d.
A friction rub

ANS: B

Rhonchi are loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration. They may be cleared by coughing. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Moist crackles are lower, more moist sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. A pleural friction rub has a dry, grating quality heard during inspiration; does not clear with coughing; heard loudest over lower lateral anterior surface.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:344

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

2.The nursing student is performing a physical examination on a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain. When would be the most appropriate time in the examination to palpate the patient’s abdomen?

a.
Palpate tender areas last.
b.
Palpate tender areas first to get it over.
c.
Palpate tender areas before inspection.
d.
Palpate before auscultation.

ANS: A

Because palpation involves the use of the hands to touch body parts and make sensitive assessments, palpate tender areas last. Palpation typically occurs right after inspection. When examining the abdomen, however, palpation occurs after auscultation. Palpate the abdomen for tenderness, distention, or masses.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:317

OBJ:Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort

3.The registered nurse is precepting a first-year nursing student. She is demonstrating how to appropriately auscultate. Auscultation is defined as which of the following?

a.
Listening with a stethoscope to sounds produced by the body
b.
Tapping the body with the fingertips to produce a vibration
c.
Becoming familiar with the nature and source of body odors
d.
Using the hands to touch body parts to make a sensitive assessment

ANS: A

Auscultation is listening for sounds produced by the body. Percussion involves tapping the body with the fingertips to produce a vibration that travels through body tissues. Olfaction, or smelling, helps to detect abnormalities not recognized by other means. Unusual smells lead to detection of serious abnormalities. Palpation involves the use of the hands to touch body parts and make sensitive assessments.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:317 | 318

OBJ:Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort

4.A patient is being seen in the health clinic for abdominal pain. The nurse will be doing a physical assessment. After using light palpation to examine the patient, the nurse uses deep palpation. With deep palpation the nurse does which of the following?

a.
Performs a completely safe method of examination
b.
Should use two hands only
c.
Uses the upper hand to exert an upward pressure
d.
Can examine the condition of organs

ANS: D

After light palpation, use deeper palpation to examine the condition of organs. Depress the area you are examining deeply and evenly. Caution is the rule. To avoid injuring a patient, do not try deep palpation without clinical supervision. Apply deep palpation with one hand or both hands (bimanually). Bimanual palpation involves one hand placed over the other while applying pressure. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:317

OBJ:Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort

5.A nurse is preparing to perform a physical examination on a patient who has mobility issues. In preparing for the examination, the nurse should do which of the following?

a.
Be sure that a well-equipped examination room is available.
b.
Tune the radio to the nurse’s favorite station to relax the patient.
c.
Perform thorough hand hygiene before preparing equipment.
d.
Instruct the patient on the safest way to transfer onto the examination table.

ANS: C

Perform hand hygiene before equipment preparation and the examination. A well-equipped examination room is preferable, but often the examination occurs in the patient’s room. In the home you may perform the examination in the patient’s bedroom. Be sure to eliminate other sources of noise, take precautions to prevent interruptions, and make sure the room is warm enough to maintain comfort. Patients with mobility impairments require safe transfer to an examination table. The patient is the expert and should be asked how to safely move from the bed to the table, either with a standing assisted transfer or by being lifted, as with a child or small adult.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:319

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control

6.A registered nurse is preparing to perform a physical examination on a 5-year-old child. To make the child feel safer during the examination the nurse should do which of the following?

a.
Examine the child’s fingernails before listening to his breath sounds.
b.
Question only the child so as to avoid unwanted parental influence.
c.
Perform palpation before visual inspection.
d.
Calls the parents by their first names to establish a more trusting bond.

ANS: A

Children will feel safer during an examination if it is initiated from the periphery and then moves to the central. For example, examine the extremities before moving to the chest. It also helps to perform parts of the examination that you can do visually before actually touching the child. When obtaining histories of infants and children, gather all or part of the information from parents or guardians. Call children by their preferred name, and address parents formally (e.g., as “Mr. and Mrs. Brown”) rather than by first names.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:320 | 321

OBJ:List techniques to promote the patient’s physical and psychological comfort during an examination.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

7.A nurse is preparing to perform a physical exam on a patient. She has found that it is best to perform the physical with a head-to-toe approach. Why is this important?

a.
The head-to-toe format excludes unnecessary body systems.
b.
It is a methodical way to include all body systems.
c.
It reduces time by allowing examination of only one side.
d.
It requires that painful procedures be done first.

ANS: B

A head-to-toe approach includes all body systems and helps to anticipate each step. In an adult, a nurse begins by assessing the head and neck, progressing methodically down the body to include all body systems. Both sides of the body must be compared for symmetry. Any painful procedures should be performed near the end of the examination.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:322

OBJ:List techniques to promote the patient’s physical and psychological comfort during an examination.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

8.A nurse is admitting a 79-year-old woman with a fractured hip to the orthopedic unit. Her husband states that she broke her hip when she tripped in her garden. Upon examination, the nurse notes purple, green, and yellow bruises on the back and arms. The patient states that those were received when she fell. The nurse should do which of the following?

a.
Ask the husband to wait in the waiting room.
b.
Ignore the bruises because the patient has provided an explanation.
c.
Realize that the patient may be abused, but that is a family issue.
d.
Prepare to discharge the patient home once treatment is complete.

ANS: A

Patients are more likely to reveal problems when the suspected abuser is not present in the room. Psychological abuse as well as obvious physical injury or neglect (e.g., evidence of malnutrition or presence of bruising on the extremities or trunk) should be assessed. If you have suspicion of abuse, find a way to interview the patient privately. If you assess a pattern of findings indicating abuse, most states mandate a report to a social service center. (Refer to state guidelines.) Obtain immediate consultation with a health care provider, social worker, and other support staff to facilitate placement in a safer environment.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 323 OBJ: Communicate abnormal findings to appropriate personnel.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

9.The student nurse has been assigned to the pediatric unit for her clinical training this semester. She is assisting with the admission of a 5-month-old infant admitted with pneumonia. The student nurse is responsible for taking the child’s vital signs and weighing and measuring the child. The infant’s mother is very concerned when the student nurse tells her that the baby weighs 14 pounds. The mother states that the baby has lost a significant amount of weight because the previous week she weighed 16 pounds at home. What is the student nurse’s best response to the mother’s concern?

a.
“To get an accurate weight, babies are weighed at different times of the day.”
b.
“Variations occur because we place our hand firmly on the child.”
c.
“Even if we use the same scale, the variation can be 1 to 2 pounds.”
d.
“Weight measurements can vary with different scales.”

ANS: D

Different scales can give different weights for patients. To ensure accurate clinical decisions, weigh patients at the same time of day, on the same scale, and in the same clothes. Hold a hand lightly above the infant to prevent accidental falls. The scale can measure in weight increments to the nearest 0.1 pound or 0.1 kg.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

10.An older adult African-American woman has gone to the clinic where a RN volunteers twice a week. She is a diabetic and has some skin breakdown on the calf of her right leg. Her skin is very darkly pigmented. To best examine the patient’s skin, the nurse should use which of the following?

a.
Halogen lighting
b.
Artificial warming to increase room temperature
c.
Natural sunlight
d.
Air conditioning to lower room temperature

ANS: C

The recommended light is natural sunlight, with halogen lighting being another option. Sunlight is the best choice for detecting skin changes in patients with darker skin. A room that is too warm causes superficial vasodilation, resulting in an increased redness of the skin. Patients who become too cold by air conditioning can develop cyanosis (bluish color) around the lips and nail beds.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:325

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

11.An older adult patient complains of thirst, headache, and weight loss. The patient appears emaciated. On physical assessment the nurse finds that the patient’s skin does not return to normal shape after being assessed. This finding is consistent with which of the following?

a.
Pallor
b.
Cyanosis
c.
Erythema
d.
Poor skin turgor

ANS: D

Turgor is the skin’s elasticity. To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. Normally the skin lifts easily and snaps back immediately to its resting position. The skin stays pinched or tented when turgor is poor. You can see pallor (unusual paleness) more easily in the face, buccal mucosa (mouth), conjunctivae, and nail beds. Localized skin changes, such as pallor or erythema (red discoloration), often indicate circulatory changes or are caused by localized vasodilation resulting from sunburn or fever. Observe for cyanosis (bluish discoloration) in the lips, nail beds, palpebral conjunctivae, and palms.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:325 | 326 | 328

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation

12.A student nurse is helping admit a 77-year-old man to the surgical floor of an acute care hospital. The patient has an abdominal tumor that is scheduled to be removed. He has had nothing by mouth (NPO) since midnight in preparation for his surgery. The student nurse notes that the patient’s skin is very dry and scaly. Which of the following should the student nurse investigate further as the most likely cause for the patient’s dry skin?

a.
Excess humidity in the patient’s living environment
b.
The use of excessive soap when bathing
c.
Lack of sun exposure leading to decreased stimulation of sweat glands
d.
Decreased levels of stress

ANS: B

Excessively dry skin is common in older adults and persons who use excessive amounts of soap during bathing. Other factors causing dry skin include lack of humidity, exposure to sun, smoking, stress, excessive perspiration, and dehydration. Excessive dryness worsens existing skin conditions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:327

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation

13.The patient recently had a cast applied to his left lower leg after a football injury in which he broke his tibia. After the application of the cast, the nurse felt the toes of his left and right feet. To assess circulation in the left foot, the nurse should do which of the following?

a.
Use the tips of her fingers to assess temperature.
b.
Expect that the temperature in the left leg will be lower than that in the right.
c.
Expect that the temperature of the left foot to be the same as the right foot.
d.
Expect that the left foot will be warmer than the left.

ANS: C

Compare symmetrical body parts, which should be the same in assessment. Always assess skin temperature for patients at risk for impaired circulation, such as after a cast application or vascular surgery. Normally the skin temperature is warm. Skin temperature is the same throughout the body. Accurately assess temperature by palpating the skin with the dorsum, or back, of the hand.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:327

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

14.An RN is assessing an 87-year-old patient who has gone to the clinic to see the health care provider for a follow-up appointment. The nurse notes that the patient looks tired and has dark circles under her eyes. She assesses her skin turgor, which is poor. She is concerned because she knows that poor skin turgor can predispose the patient to which of the following?

a.
Dehydration
b.
Edema
c.
Skin breakdown
d.
Direct trauma

ANS: C

A decrease in turgor predisposes a patient to skin breakdown. Turgor is the skin’s elasticity. Normally the skin loses its elasticity with age. Edema or dehydration diminishes turgor. Direct trauma and impairment of venous return are two common causes of edema.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:328

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

15.A single mother with three school-age children has recently noticed that the second child has been scratching his head and complains that it itches. She asks the school nurse to examine him. The school nurse notes that the child has head lice. Which of the following is the best description of head lice?

a.
Lice are easy to see and look like little white crabs.
b.
Lice are difficult to see, but their eggs are small oval particles.
c.
Lice and their eggs are on the hair shafts and look like dandruff.
d.
Treatment for lice can wait until the entire family can be checked.

ANS: B

Head and crab lice attach their eggs to hair. Lice eggs look like oval particles of dandruff. The lice themselves are difficult to see. Observe for bites or pustular eruptions in the follicles and in areas where skin surfaces meet, such as behind the ears and in the groin. The discovery of lice requires immediate treatment and family education.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:329

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

16.The nurse is assessing an older adult who has smoked for the past 47 years and has been diagnosed with chronic obstructive pulmonary disease. Which of the following would the nurse expect to see upon physical examination of the patient?

a.
Pallor and hardening of the nail bed
b.
Jaundice in the nail bed
c.
An angle greater than 160 degrees between the nail and nail bed
d.
An angle less than 160 degrees between the nail and nail bed

ANS: C

Inspection of the angle between the nail and nail bed normally reveals an angle of 160 degrees. A larger angle and softening of the nail bed indicate chronic oxygenation problems. An ongoing bluish or purplish cast to the nail bed occurs with cyanosis. A white cast or pallor results from anemia. Observe for jaundice (yellow-orange), which indicates liver disease.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:330

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

17.A 47-year-old patient is being treated for hyperthyroidism. When she goes to the health care provider for a check-up, the nurse in the clinic expects to see which of the following physical symptoms?

a.
Exophthalmos
b.
Strabismus
c.
Photophobia
d.
Diplopia

ANS: A

Bulging eyes (exophthalmos) usually indicate hyperthyroidism. The crossing of eyes (strabismus) results from neuromuscular injury or inherited abnormalities. Assess for common symptoms of eye disease such as eye pain, photophobia (sensitivity to light), burning, itching, excessive tearing, diplopia (double vision), blurred vision, or visual disturbances (e.g., flashing lights, halos, or “film” over vision field).

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:331

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

18.The nurse is assessing an elderly patient and notices a significant drooping of the eyelid. The nurse recognizes this as which of the following?

a.
Ectropion of the eyelid
b.
Entropion of the eyelid
c.
Impairment of the fourth cranial nerve
d.
Ptosis of the eyelid

ANS: D

An abnormal drooping of the lid over the pupil is called ptosis, caused by edema or impairment of the third cranial nerve. In the older adult, ptosis results from a loss of elasticity that accompanies aging. An older adult frequently has lid margins that turn out (ectropion) or in (entropion).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:332

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

19.A 17 year old was taken to the emergency department when his mother found him unresponsive. Upon examination, his pupils were found to be pinpoints. This is a common sign of which of the following?

a.
Opioid intoxication
b.
Arcus senilis
c.
Cataracts
d.
Opioid withdrawal

ANS: A

Pinpoint pupils are a common sign of opioid intoxication. A thin white ring along the margin of the iris, called an arcus senilis, is common with aging but is abnormal in anyone less than age 40. Cloudy pupils indicate cataracts. Continuous dilation of pupils results from neurological disorders, glaucoma, trauma, eye medication, or withdrawal from opioids.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:333

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

20.On examination of an 18-month-old child, the nurse found the right eardrum pink and bulging. How should a normal eardrum appear?

a.
Pink
b.
Red
c.
Pearly gray
d.
White

ANS: C

The normal eardrum is translucent, shiny, and pearly gray. It is free from tears or breaks. A pink or red bulging membrane indicates inflammation. A white color reveals pus behind it. The membrane is taut, except for the small triangular pars flaccida near the top. If cerumen is blocking the tympanic membrane, warm water irrigation will safely remove the wax.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:335

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

21.A woman went to the public health clinic with a fever that had persisted for several days. Upon palpation of the neck, a registered nurse found several large lymph nodes. What is the nurse’s best response to this patient upon palpating her lymph nodes?

a.
“There is no need to worry; enlarged lymph nodes are normal findings.”
b.
“Lymph nodes are not really significant because they really have no function.”
c.
“Most people have a few enlarged lymph nodes.”
d.
“Enlarged lymph nodes sometimes indicate an infection.”

ANS: D

Lymph nodes that are large, fixed, inflamed, or tender indicate a problem such as local infection, systemic disease, or neoplasm. Enlarged lymph nodes are not normal. Normally lymph nodes are not easily palpable. An extensive system of lymph nodes collects lymph from the head, ears, nose, cheeks, and lips.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:339

OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

22.A 45-year-old gay man who lives with a partner of 19 years recently has developed a persistent cough and night sweats from which he wakes up soaked. The nurse who is caring for the man should be most concerned about which of the following conditions?

a.
Lung cancer
b.
Tuberculosis
c.
Orthopnea
d.
Cardiopulmonary disease

ANS: B

Persistent cough and night sweats are symptoms of tuberculosis (TB). Review risk factors for TB and/or HIV infection and assess for symptoms, including persistent cough, hemoptysis, unexplained weight loss, fatigue, anorexia, night sweats, and fever. Ask the patient about persistent cough (productive or nonproductive), blood-streaked sputum, voice change, chest pain, shortness of breath, orthopnea (must be in upright position to breathe), dyspnea (breathlessness) during exertion or at rest, poor activity tolerance, or recurrent pneumonia or bronchitis. This may reveal cardiopulmonary problems or warning signs for lung cancer (symptoms in italics).

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:341 | 342

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

23.A nurse inspects the thorax of an older adult patient who has chronic lung disease. An expected finding would be a(n):

a.
round shape of the chest.
b.
barrel-shaped chest.
c.
AP diameter greater than the transverse diameter.
d.
AP diameter less than the transverse diameter.

ANS: B

In adults, a barrel-shaped chest (AP diameter = transverse) characterizes chronic lung disease. Normally the chest is symmetrical, with the anteroposterior diameter one third to one half the size of the transverse diameter. Infants have an almost round shape with a 1:1 ratio between the AP and transverse diameters. In addition, a more rounded chest is associated with older age.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:342

OBJ:Discuss normal physical findings for patients across the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

24.A nurse can best auscultate the point of maximum impulse (PMI) in a teenager at the _____ intercostal space, _____ midclavicular line.

a.
fifth; left
b.
fourth; left
c.
fifth; right
d.
fourth; right

ANS: A

The point of maximal impulse (PMI) is palpable at the fifth intercostal space at the left midclavicular line in adults and children older than 7 years of age. In children younger than age 7 the PMI is at the fourth intercostal space at the left midclavicular line

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:345

OBJ:Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

25.At a point during the admission process of a young female patient, the nurse asks the patient about whether or not she performs self-breast examinations. The patient asks about the best time of the month to perform this examination. What is the best response?

a.
“Usually the first day of your menstrual period is best.”
b.
“At the same time every month.”
c.
“If you’re pregnant there is no need to do it.”
d.
“A few days after your menstrual period ends.”

ANS: D

The best time for BSE is when the breasts are not tender or swollen, usually a few days after a menstrual period ends. If the woman is postmenopausal, advise her to check her breasts on the same day each month. A pregnant woman should also check her breasts on a monthly basis.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:353

OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

26.The nurse is caring for a 22-year-old woman who has come in for a routine examination. The patient asks about how often she should perform breast self-examinations and get a mammogram. The nurse should inform the patient of which of the following?

a.
Monthly breast self-examinations are optional for women in their twenties and thirties.
b.
Women less than 40 need a clinical breast exam by a health care provider yearly.
c.
Asymptomatic women need mammograms yearly until age 40.
d.
Women greater than age 40 need mammograms every 6 months.

ANS: A

Monthly BSE is an option for women in their twenties and thirties. Women 20 years of age and older need to report any breast changes to a health care provider immediately. Women need a clinical breast examination by a health care provider every 3 years from age 20 to 40, and yearly for women greater than age 40. Women with a family history of breast cancer need a yearly examination by a health care provider. Asymptomatic women need a screening mammogram by age 40; women age 40 and older need an annual mammogram. For women with an increased risk, the ACS recommends discussion of screening options and additional testing with a health care provider.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:353

OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

27.A nurse uses four basic skills during a physical assessment. While assessing the abdomen the nurse must begin with which of the following skills?

a.
Light palpation
b.
Inspection
c.
Deep palpation
d.
Auscultation

ANS: B

The order of abdominal assessment differs from previous assessments. First the nurse begins by inspection, followed by auscultation. By using auscultation before palpation (light or deep), there is less chance of altering the frequency and character of bowel sounds.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:358

OBJ:Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

28.An adolescent is examined and told that she has a sexually transmitted disease (STI). The patient is shocked and states, “How can that be. I would know if I had a problem down there wouldn’t I?” What is the most appropriate response by the nurse?

a.
“You should have known. It’s pretty hard to miss.”
b.
“Usually STIs show up within 2 to 3 days of exposure.”
c.
“If you’d like, we can teach you some self-examination techniques.”
d.
“It’s just bad luck. We’ll clear this up and that will be the end of it.”

ANS: C

Patients who are at risk for contracting STIs need to learn to perform a genital self-examination. The purpose of the examination is to detect any signs or symptoms of STIs. Many persons do not know they have an STI (e.g., chlamydial infection), and some STIs (e.g., syphilis) can remain undetected for years. Therefore it is essential to stress the importance of regular screening for STIs in sexually active individuals.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:362

OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

29.A nurse is assisting with a female genitalia examination. The nurse will assist the patient to which position?

a.
Supine
b.
Lithotomy
c.
Knee-chest
d.
Dorsal recumbent

ANS: B

The lithotomy position provides maximal exposure of the rectal area. The supine position is used to assess the head, neck, anterior thorax, lungs, breasts, axillae, heart, abdomen, extremities, and pulses. It is the most normally relaxed position. The knee-chest position is used to examine the rectum. The dorsal recumbent position is used to assess the head, neck, anterior thorax, lungs, breasts, axillae, heart, and abdomen. This position is used for abdominal assessment because it promotes relation of abdominal muscles.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:321

OBJ: Describe proper positioning for the patient during each phase of the examination.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

30.A patient is complaining of nonspecific abdominal pain. What is the technique the nurse uses to assess tenderness?

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

ANS: A

Palpation primarily detects areas of abdominal tenderness, distention, or masses. Percussion involves tapping the body with the fingertips to produce a vibration that travels through body tissues. The resulting sounds give information about the location, size, and density of underlying structures and help verify abnormalities assessed by palpation and auscultation. Auscultation is listening for sounds produced by the body and is not used to assess tenderness. Olfaction, or smelling, helps to detect abnormalities not recognized by other means. Unusual smells can lead to detection of serious abnormalities.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:317 | 318 | 319

OBJ:Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

MULTIPLE RESPONSE

1.A nurse is meeting a patient for the first time. The importance of establishing baseline data is that it will enable the nurse to assess which of the following? (Select all that apply.)

a.
Know the baseline information about the patient’s health status.
b.
Supplement, confirm, or refute information learned during the history taking.
c.
Identify or confirm nursing diagnoses.
d.
Assess the patient’s understanding of the disease process.
e.
Focus on a specific body system.

ANS: A, B, C, D

Use a physical assessment to gather baseline information about the patient’s health status, supplement, confirm, or refute information learned during the history taking, identify or confirm nursing diagnoses, make clinical judgments about the patient’s current or changing health status and ability to manage it, and evaluate the outcomes of care. A focused health assessment is selected to gather information related to a specific body system, as happens when a patient first presents to the hospital or for a specific screening purpose, such as for cholesterol or blood glucose levels.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 315 | 316 OBJ: Discuss the purposes of the health assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

2.A patient is admitted from the emergency department. The nurse notices that the patient and family are anxious. During the admission process the nurse should do which of the following? (Select all that apply.)

a.
Continue with the examination even if the patient is anxious to get it done.
b.
Disregard cultural differences to gather therapeutic data.
c.
Provide a thorough explanation of the purpose of each assessment.
d.
Provide a thorough explanation of the steps of each assessment.
e.
Maintain a formal professional approach.

ANS: C, D

Many patients find an examination tiring or stressful, or they experience anxiety about possible findings. A thorough, simple, and clear explanation of the purpose and steps of each assessment lets patients know what to expect and helps them cooperate with each step. As you examine each body system, give a detailed explanation. Convey an open, professional, and relaxed approach. A stiff, formal approach will inhibit the patient’s ability to communicate, but being too casual will not give the patient confidence in your ability. It is sometimes necessary to stop the examination and ask how the patient feels. Do not force a patient to continue. Findings will be more accurate if you postpone for when the patient can cooperate and relax. Remember that cultural differences influence a patient’s behavior. Consider the patient’s health beliefs, use of alternative therapies, nutritional habits, relationships with family, and comfort with your physical closeness during the examination and history taking. If necessary, obtain a medical translator who can correctly interpret to a patient who does not speak English.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:316 | 320

OBJ: Prepare a therapeutic environment before the physical examination.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

3.Risk factors for breast cancer in women include which of the following? (Select all that apply.)

a.
Age greater than 40
b.
BRCA 1 and 2 gene mutations
c.
Late onset menarche
d.
Early menopause
e.
Use of contraceptives

ANS: A, B, E

Risk factors include being a woman greater than age 40, a personal or family history of breast cancer, especially with the BRCA1 and BRCA2 inherited gene mutations. Also early-onset menarche (before age 12), or late-age menopause (after age 55) affect risk. Other risk factors include never having children, giving birth to the first child after age 30, recent use of oral contraceptives, previous chest radiation, alcohol use, and being overweight.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:353

OBJ: Identify data to collect from the nursing history before an examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential