Nur 202 Health Assessment Exam 1
Questions with Correct Answers
Before auscultating the lungs of a child, the nurse asks the parent to remove the child's
gown. What could be the reason for such an intervention?
1
To avoid sound artifacts
2
To avoid the chandelier sign
3
To listen to high-pitched sounds
4
To listen to low-pitched sounds - Answer-1
To avoid sound artifacts
A stethoscope is used to assess the lung sounds during auscultation. The nurse should
not auscultate through the patient's clothing, because this creates sound artifacts and
dampens the original lung sounds of the patient. Holding the bell endpiece lightly
against patient's skin helps the nurse to listen to low-pitched sounds. Holding the
diaphragm firmly against the child's skin helps the nurse to listen to high-frequency
sounds. Warming the end of the stethoscope helps to avoid chandelier sign.
Which is the major task of infancy according to Erikson's stages of psychosocial
development?
1
Developing a sense of trust
2
Developing a sense of industry
3
Developing a sense of initiative
4
Developing a sense of autonomy - Answer-1
Developing a sense of trust
An infant is completely dependent on the parent for basic needs. If these needs are met
promptly and consistently, then the infant feels secure and learns to trust others. Thus,
according to Erikson, establishing trust is the major task of an infant during
development. Developing a sense of industry is a major task in a school-age child,
because at this age the child develops basic competency. The preschool child desires
to plan and perform tasks independently. Therefore, developing initiative is a major task
for a preschool child. The toddler displays explorative behavior and desires to be
independent. Thus, developing autonomy is a major task for a toddler.
While performing a physical examination, the nurse taps the patient's skin with short,
sharp strokes. What is the reason for this nursing assessment?
,1
Percussion
2
Auscultation
3
Palpation
4
Inspection - Answer-1
Percussion
The nurse is performing percussion. In percussion, the patient's skin is tapped with
short, sharp strokes to assess underlying structures. The strokes yield a palpable
vibration and a characteristic sound that depicts the location, size, and density of the
underlying organ. Auscultation involves listening to different sounds produced by
organs, such as the heart, blood vessels, lungs, and abdomen. The process of
palpation involves the nurse's touch to assess factors such as swelling, vibration, rigidity
or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or
pain. Inspection involves close, careful scrutiny, first of the patient as a whole and then
of each body system.
Which part of the hand should the nurse use to assess the skin texture, swelling, and
the presence of lumps during palpation?
1
Fingertips
2
Base of fingers
3
Fingers and thumb
4
The backs of the hands and fingers - Answer-1
Fingertips
The fingertips are rich in sensory nerve endings. Therefore, the fingertips are the best to
palpate skin texture, fluid accumulation, and presence of an abnormal body mass. The
base of the fingers or ulnar surfaces of the hand are best for assessing vibrations of
body cavities. A grasping action of the fingers and the thumb is best to determine the
placement, spatial arrangement, and consistency of organs. The backs of the hands
and fingers are best for determining body temperature, because of the presence of thin
skin.
The nurse wants to auscultate the lungs of a patient. What should the nurse do if the
patient has excessive chest hair?
1
Shave the patient's chest hair.
2
Moisten the patient's chest hair.
, 3
Clean the stethoscope endpiece with an alcohol wipe.
4
Warm the stethoscope endpiece by rubbing it with the palm. - Answer-2
Moisten the patient's chest hair.
The nurse should wet the patient's chest hair before auscultating the lungs to prevent
crackling sounds produced by friction between the stethoscope endpiece and the chest
hair. Shaving the chest hair is not appropriate for a routine auscultation procedure. The
nurse should clean the stethoscope endpiece with an alcohol wipe to prevent the
transfer of pathogens from one patient to another. This does not interfere with the
auscultations. The nurse should warm the endpiece of the stethoscope by rubbing it
with hands to prevent contraction of the chest muscles, which may occur when a cold
endpiece is placed on a warm chest.
The patient enters the examination room for a physical assessment. The nurse switches
on all the lights and stares at the patient for a few minutes before starting any
procedure. What is the reason for this behavior by the nurse?
1
The nurse is doing inspection.
2
The nurse is doing auscultation.
3
The nurse is doing palpation.
4
The nurse is doing percussion. - Answer-1
The nurse is doing inspection.
The nurse is inspecting the patient carefully. Inspection involves close, careful scrutiny,
first of the patient as a whole and then of each body system. The procedure requires
intense concentration and involves staring at the patient. For proper and minute
observation, the place where the patient is inspected must be brightly lit. Auscultation is
listening to the sounds produced by the body such as the heart, blood vessels, lungs,
and abdomen. The process of palpation applies the nurse's sense of touch to assess
factors such as swelling, vibration or pulsation, rigidity or spasticity, crepitation,
presence of lumps or masses, and presence of tenderness or pain. Percussion involves
tapping the patient's skin with short, sharp strokes to assess the underlying structures.
Which equipment would the nurse use to measure the range of motion of a shoulder
joint?
1
Goniometer
2
Monofilament
3
Ophthalmoscope
