NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Ba nk | Questions and A nswers with Rationale 1. The nurse will use which technique of assessment to determine the presence of c repitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation RAT: Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pai n. 2. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is often used to direct light onto the sinuses. b. Uses a short, broad speculum to help visualize the ear. c. Is used to examine the structures of the internal ear. d. Directs light into the ear canal and onto the tympanic membrane. RAT: The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares. 3. An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is bein g correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus RAT: The ophthalmoscope is used to examine the internal eye s tructures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. 4. The nurse is unable to palpate the right radial pulse on a patient. The best action would be Stuvia.com - The Marketplace to Buy and Sell your Study Material
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to: 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. d. Check for the presence of pulsations with a stethoscope. RAT: Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. 5. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a. Perform s the examination from the left side of the bed. b. Examines t ender or painful areas first to help relieve the patient’s anxiety. c. Follows the same examination sequence, regardless of the patient’s age or condition. d. Organizes the assessment to ensu re that the patient does not change positions too often. RAT: The steps of the assessment should be organized to ensure that the patient does not change positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last. 6. A man is at the clinic for a physical examination. He states that he is “very anxious” about the physical examination. What steps can the nurse take to make h im more comfortable? a. Appear unhurried and confident when exam ining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs u ntil the end of the examination, which allows him time to become comfortable. RAT: Anxiety can be reduced by an examiner who is confident, self -assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person’s vital signs, will gradually accustom the person to the examination. 7. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when per forming a physical examination? a. Washing one’s hands after removing gloves is not necessary, as long as the gloves are still intact. b. Hands are washed before and after every physical patient en counter. c. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient Stuvia.com - The Marketplace to Buy and Sell your Study Material
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concern regarding the sprea d of infectious diseases. RAT: The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present. 8. The nurse is examining a patient’s lower leg and n otices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing hands, and contacting the physician b. Continuing to examine the ulceration, and then washing hands c. Washing hands, putting on gloves, and continuing with the examination of the ulceration d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration RAT: The examiner should wear gloves when the potential contact with any body flu ids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. 9. During the examination, offering some brief t eaching about the patient’s body or the examiner’s findings is often appropr iate. Which one of these statements by the nurse is most appropriate? a. “Your atrial dysrhythmias are under control.” b. “You have pitting edema and mild varicosities.” c. “Your pulse is 80 beats per minute, which is within the normal range.” d. “I’m u sing my stethoscope to listen for any crackles, wheezes, or rubs.” RAT: The sharing of some information builds rapport, as long as the patient is able to understand the terminology. 10. The nurse keeps in mind that the most important reason to share i nformation and to offer brief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation. b. Examiner to build rapport and to increase the patient’s confidence in him or her. c. Patient understand his or her disease process and treatment modalities. d. Patient identify questions about his or her disease and the potential areas of patient education. RAT: Sharing information builds rapport and increases the patient’s confiden ce in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present. 11. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination ? Stuvia.com - The Marketplace to Buy and Sell your Study Material
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a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. Halfway through the examination RAT: The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cr y. 12. When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the in fant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infant’s vital signs. RAT: The parent should always be present to increase the child’s feeling of security and to understand no rmal growth and development. The timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed, but a diaper should be left on a boy. 13. A 6-month -old infant has been brought to the well -child clinic for a check -up. She is currently sleeping. What s hould the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant’s hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of the examination in a head -to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain th e most accurate assessment of body systems. RAT: When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures that should be perform ed at the end of the examination. 14. A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent r emove all of the child’s clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus the interactions on the child, essentially ignoring the parent until the child’s tr ust has been obtained. RAT: The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2 -year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one Stuvia.com - The Marketplace to Buy and Sell your Study Material
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