1.The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
a.
Inspection usually yields little information.
b.
Inspection takes time and reveals a surprising amount of information.
c.
Inspection may be somewhat u...
Gonzaga university: Nursing 600/601 questions with
correct answers
1.The nurse is preparing to perform a physical assessment. Which
statement is true about the inspection phase of the physical assessment?
a.
Inspection usually yields little information.
b.
Inspection takes time and reveals a surprising amount of information.
c.
Inspection may be somewhat uncomfortable for the expert practitioner.
d.
Inspection requires a quick glance at the patient's body systems before
proceeding on with palpation. Correct Answer-B
A focused inspection takes time and yields a surprising amount of
information. Initially, the examiner may feel uncomfortable "staring" at
the person without also "doing something." A focused assessment is
much more than a "quick glance."
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 Correct Answer-B
Bimanual palpation requires the use of both hands to envelop or capture
certain body parts or organs such as the kidneys, uterus, or adnexa. The
other situations are not appropriate for bimanual palpation.
The nurse is preparing to percuss the abdomen of a patient. The purpose
of the percussion is to assess the underlying tissue:
a. turgor.
b. texture.
c. density.
d. consistency. Correct Answer-C
Percussion yields a sound that depicts the location, size, and density of
the underlying organ. Turgor and texture are assessed with palpation
The nurse is reviewing percussion techniques with a newly graduated
nurse. Which technique, if used by the new nurse, indicates that more
review is needed? The nurse:
a. percusses once over each area.
b. lifts the striking finger off quickly after each stroke.
c. strikes with the finger tip, not the finger pad.
d. uses the wrist to make the strikes, not the arm. Correct Answer-A
For percussion, the nurse should percuss two times over each location.
The striking finger should be lifted off quickly because a resting finger
,damps off vibrations. The tip of the striking finger should make contact,
not the pad of the finger. The wrist must be relaxed, and it is used to
make the strikes, not the arm.
When percussing over the liver of a patient, the nurse notices a dull
sound. The nurse should:
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 an abnormal finding and refer the patient for additional
treatment. Correct Answer-A
Percussion over relatively dense organs, such as the liver or spleen, will
produce a dull sound. The other responses are not correct.
The nurse hears bilateral louder, longer, and lower tones when
percussing over the lungs of a 4-year-old child. What should the nurse
do next?
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of an increased amount of air in
the lungs.
d. Consider this a normal finding for a child this age and proceed with
the examination. Correct Answer-D
, Percussion notes that are louder in amplitude, lower in pitch, of a
booming quality, and longer in duration are normal over a child's lung.
A patient has suddenly developed shortness of breath and appears to be
in significant respiratory distress. After putting a call in to the physician
and placing the patient on oxygen, which of these is the best action for
the nurse to take when assessing the patient further?
a. Count the patient's respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion
tones.
c. Call for a chest x-ray and wait for the results before beginning an
assessment.
d. Inspect the thorax for any new masses and bleeding associated with
respirations. Correct Answer-B
Percussion is always available, portable, and gives instant feedback
regarding changes in underlying tissue density, which may yield clues of
the patient's physical status.
The nurse is preparing to use a stethoscope for auscultation. Which
statement is true regarding the diaphragm of the stethoscope? The
diaphragm:
a. is used to listen for high-pitched sounds.
b. is used to listen for low-pitched sounds.
c. should be held lightly against the person's skin to block out low-
pitched sounds.
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