Question 1

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath.How should the nurse proceed with the assessment?

Accepted Answer

It may be necessary in this situation to alter the position of the patient during the examination and to collect a mini-database by examining the body areas directly related to the problem for which the patient has been hospitalized.You can return later to do a complete assessment after the problem has been resolved.

Question 2

When preparing to perform a physical examination on an infant,the examiner should:

Accepted Answer

The parent should always be present to ensure the child's feeling of security and to get information about the child's normal growth and development.The examination should be conducted 1 to 2 hours after the baby has been fed so that he or she is not too drowsy or hungry.Infants usually have no problem with being undressed;clothing should be removed and a diaper left on a male infant.

Question 3

The most important step that the nurse can take to prevent transmission of infections in the hospital setting is to:

Accepted Answer

The most important step to decrease the risk of microorganism transmission is to wash your hands promptly before and after physical contact with each patient.Stethoscopes should also be cleaned with an alcohol swab between patients.

Question 4

The most important reason to share information and offer brief education while performing the physical examination is to help:

Accepted Answer

Sharing of information builds rapport and increases the patient's confidence in you as an examiner.It also gives the patient a little more control in a situation in which it is easy to feel completely helpless.

Question 5

During the examination,it is often appropriate to offer some education to the patient about the findings.Which of the following statements by the nurse is most appropriate?

Accepted Answer

Sharing of information builds rapport as long as the patient is able to understand the terminology used.

Question 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 examiner take to make him feel more comfortable?

Accepted Answer

Anxiety can be reduced by an examiner who is confident,self-assured,considerate,and unhurried.Familiar and relatively nonthreatening actions,such as measuring vital signs,will gradually accustom the person to the examination.

Question 7

While auscultating for heart sounds,the nurse hears a murmur.Which of the following should be used to assess this murmur?

Accepted Answer

Using the bell of the stethoscope is best to detect soft,low-pitched sounds such as extra heart sounds or murmurs.

Question 8

A 6-month-old infant has been brought to the well-child clinic for a checkup.She is currently sleeping.What should the examiner do first?

Accepted Answer

The ideal time to assess the cardiac,respiratory,and abdominal systems is when the infant is quiet or sleeping.Assessment of the eye,ear,nose,and throat are invasive procedures and should be performed at the end of the examination.

Question 9

The nurse is examining a patient's lower leg and notes a draining ulcer.Which of the following actions is most appropriate in this situation?

Accepted Answer

The examiner should wear gloves when there is potential for contact with any body fluids.In this situation,you should wash your hands,put on gloves,and continue examining the ulcer.

Question 10

When examining infants,the nurse will elicit the Moro reflex:

Accepted Answer

Eliciting the Moro or "startle" reflex should be done at the end of the examination because it may cause the baby to cry.

Question 11

Which of the following statements about the application of routine practices in the health care setting is true?

Accepted Answer

Routine practices are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources.They apply to all instances of contact with blood and all other body fluids,secretions,and excretions,except sweat,regardless of whether they contain visible blood,nonintact skin,or mucous membranes.

Question 12

During the examination of a patient's abdomen,the nurse notes that the abdomen is rounded and firm to the touch.Percussion produces a drumlike sound across the quadrants.This type of sound indicates:

Accepted Answer

A musical or drumlike sound (tympany)is heard during percussion over air-filled viscus,such as the stomach or intestines.

Question 13

When performing a physical examination,safety measures must be taken to protect the examiner and the patient against infections.Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?

Accepted Answer

The examiner should wash hands at the beginning of the examination and each time he or she re-enters the room.Gloves should be worn when there is potential for contact with any body fluids.Hands should be washed after gloves have been removed,even if the gloves appear to be intact.

Question 14

When examining an infant,which area should the nurse examine first?

Accepted Answer

Perform the least distressing steps first.Save the invasive steps-examination of the eye,ear,nose,and throat-until last.

Question 15

The nurse is preparing to examine a 4-year-old child.Which of the following actions is appropriate as the first step?

Accepted Answer

With preschool children,use short,simple explanations.Children at this age are usually willing to undress.Examination of the head should be performed last.During the examination,give the preschooler feedback and reassurance.

Question 16

The nurse is examining a 2-year-old child and asks,"May I listen to your heart now?" Which of the following critiques of her technique is most accurate?

Accepted Answer

Children at this age like to say no.Do not offer a choice when there really is none.If the child says no,and you go ahead and do it anyway,you lose trust.Autonomy is enhanced by offering a limited option: "Shall I listen to your heart next,or to your tummy?"

Question 17

When examining the older adult,the nurse should:

Accepted Answer

When examining the older adult,it is best to organize the sequence of the examination steps so that there are as few position changes as possible.Physical touch is especially important in the case of older adults because their other senses may have diminished function.

Question 18

With which of the following patients would it be most appropriate to use games during the assessment,such as having the patient "blow out" the light on the penlight?

Accepted Answer

When assessing preschool children,it is helpful to use games or allow them to play with small instruments used in the examination to reduce their fears.

Question 19

A 2-year-old child has been brought to the clinic for a well-child checkup.How should the examiner proceed with the assessment?

Accepted Answer

Examining the toddler is best done when he or she is sitting on the parent's lap.Toddlers understand symbols,so using a security object is helpful.Initially,focus more on the parent.This allows the child to gradually adjust to and become familiar with you.A 2-year-old does not like to have all of his or her clothes removed.Have the parent undress the child gradually.

Question 20

When examining a 16-year-old male teenager,the examiner should:

Accepted Answer

During the examination,the adolescent needs feedback that his or her body is healthy and developing normally.The adolescent has a keen awareness of body image,often comparing himself or herself to peers.Apprise the adolescent of the wide variations among teenagers in the rates of growth and development.

Quiz 9: Assessment Techniques and the Clinical Setting