Question 1

The use of secondary, tangential lighting is most helpful in the detection of:

Accepted Answer

Tangential lighting is used to cast shadows to observe contours and variations in body surfaces best.

Question 2

Expected normal percussion tones include:

Accepted Answer

A normal lung produces resonance percussion tones, whereas an empty stomach is expected to produce tympany. Dullness indicates atelectasis of the lung. Hyperresonance over the lungs indicates emphysema. Flatness occurs over muscle.

Question 3

During percussion, a dull tone is expected to be heard over:

Accepted Answer

Dull tones are expected over denser areas such as the liver. Healthy lung tissue is resonant. Emphysemic lungs are hyperresonant. Tympany is heard over most of the abdomen.

Question 4

Which technique is commonly used to elicit tenderness arising from the liver, gallbladder, or kidneys?

Accepted Answer

Fist percussion is a direct percussion technique used to elicit tenderness over organs such as the liver, gallbladder, or kidneys.

Question 5

The height-measuring attachment of the standing platform scale should be pulled up:

Accepted Answer

To ensure patient safety, the arm of the height-measuring attachment should be pulled up before the patient steps on the scale, after the scale is balanced, and before weight is assessed.

Question 6

According to the guidelines for Standard Precautions, the caregiver's hands should be washed:

Accepted Answer

Handwashing is to be done after removal of gloves, between patient contacts, and after touching body fluids, regardless of whether gloves are used. The nurse should never touch body fluids or blood products with ungloved hands. The nurse should use hand hygiene regardless of a patient's possible infection.

Question 7

When using mediate or indirect percussion, which technique is appropriate?

Accepted Answer

The palmar surface of the nondominant (stationary) hand should rest against the body surface, with the fingers spread slightly. A helpful tip to improve elicitation of correct tones is to hyperextend the middle finger of the stationary hand and place the distal interphalangeal joint firmly against the body surface. This lifting of the fingertip avoids dampening of the vibratory sounds.

Question 8

Auscultation should be carried out last, except when examining the:

Accepted Answer

Auscultation is the last examination technique used for all areas except the abdomen. In this case, it is performed after inspection.

Question 9

The dorsal surface of the hand is most often used for the assessment of:

Accepted Answer

The dorsal surface, or back of the hand, is best for assessing warmth, or temperature. The palmar surface, rather than the dorsal surface, is best for assessing crepitus. The palmar surface, rather than the dorsal surface, is best for assessing texture. The ulnar surfaces of the hand and fingers, rather than the dorsal surface, are best for assessing vibration.

Question 10

A scale used to assess patients' weight should be calibrated:

Accepted Answer

Obtaining weight begins with a manual calibration of the scale before the patient stands on the scale. Electronic scales are automatically calibrated before each reading. The manufacturer does not calibrate the scale after it is sold. A qualified technician does not calibrate the scale at regularly scheduled intervals. Scales cannot be calibrated with the patient standing on the scale.

Question 11

During auscultation, you can limit your perceptual field best by:

Accepted Answer

By closing your eyes, your sense of hearing becomes more acute, and it increases your ability to isolate sounds. Asking patients to describe their symptoms does not assist in the technique of auscultation. The only time that auscultation occurs before percussion is in examination of the abdomen. Using an aneroid manometer does not assist in the technique of auscultation. During auscultation, the only equipment needed is the stethoscope.

Question 12

During percussion, the downward snap of the striking fingers should originate from the:

Accepted Answer

The downward snap of the striking fingers should originate from the wrist.

Question 13

You are auscultating a patient's chest. The sounds are not clear, and you are having difficulty distinguishing between respirations and heartbeats. Which technique can you use to facilitate your assessment?

Accepted Answer

If you are hearing everything at once, it is more difficult to distinguish different sounds. Try isolating each segment and listen to that segment intently; then move on to another segment. For example, listen only to breath sounds, then only to inspiratory breath sounds, and then only to expiratory breath sounds. Anticipating the next sounds will not facilitate the assessment. Listening to all sounds together will not facilitate the assessment. One of the most difficult achievements in auscultation is learning to isolate sounds. Moving the stethoscope clockwise will not facilitate the assessment.

Question 14

The degree of percussion tone is determined by the density of the medium through which the sound waves travel. Which statement is true regarding the relationship between density of the medium and percussion tone?

Accepted Answer

Percussion sounds vary according to the tissue being percussed. Less dense tissue (such as that over normal lungs) produces a loud tone, whereas more dense tissue (such as a muscle) produces a softer tone. The more dense the medium, the softer is the percussion tone. The more hollow the area, the louder is the percussion tone. Percussion tones over muscle are soft and flat.

Question 15

Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process?

Accepted Answer

Auscultation precedes palpation or percussion of the abdomen because these techniques can stimulate peristalsis, which may alter correct assessment of the abdominal sounds. Light palpation, deep palpation, and percussion should not be completed until auscultation is completed.

Question 16

You are caring for a nonambulatory 80-year-old male patient and he tells you, a female nurse, that he feels like he is having drainage from his rectum. Which initial nursing action is appropriate?

Accepted Answer

Necessary exposure for direct observation, while adjusting for modesty, is warranted. The complaint warrants validation before referral or delegation. Before you call the clinician, you need to assess the patient. The assessment should not wait for another shift. Before treatment, it is important to assess the complaint.

Question 17

Which patient is at the highest risk for developing latex allergy?

Accepted Answer

The patient who has had multiple procedures or surgeries has a higher rate of exposure to rubber gloves and to equipment and supplies that contain latex and therefore is at a higher risk for developing an allergic response.

Question 18

Which technique is used during both the history taking and the physical examination process?

Accepted Answer

Inspection is the technique that is used while gathering and validating data during both the history taking and the actual hands-on physical examination. Auscultation, palpation, and percussion are not used during the history taking and physical examination processes. It is not possible to listen to the patient talking and use the stethoscope at the same time. The focus is on the patient's response to your touch and what you are feeling; it is not possible to perform palpation and listen to the patient talking at the same time.

Question 19

Tympanic thermometers measure body temperature when a probe is placed:

Accepted Answer

Tympanic thermometer probes are placed at the external opening of the auditory canal.

Question 20

You are planning to palpate the abdomen of your patient. Which part of the examiner's hand is best for palpating vibration?

Accepted Answer

The ulnar surface of the hand and bases of the fingers can best feel vibratory sensations such as thrills and fremitus. The dorsal surface of the hand is best for assessing temperature. The finger pads and fingertips are best for palpating pulses.

Quiz 3: Examination Techniques and Equipment