Question 1

A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective?

Accepted Answer

Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety is the only objective assessment finding. All other options are examples of subjective data.

Question 2

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per min-ute?

Accepted Answer

The normal rate of bowel sounds per minute is 4 to 32.

Question 3

During a head-to-toe assessment, the nurse assesses the patient's perineal area. Which area should the nurse assess next?

Accepted Answer

When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.

Question 4

An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?

Accepted Answer

Dehydration results in decreased skin turgor.

Question 5

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

Accepted Answer

Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data.

Question 6

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

Accepted Answer

Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritus is the only subjective assessment finding. All other options are examples of objective data.

Question 7

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

Accepted Answer

Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data.

Question 8

When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique?

Accepted Answer

Deep palpation is used to detect tenderness or masses of the abdomen.

Question 9

The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds?

Accepted Answer

Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.

Question 10

What is the suggested sequence for a systematic approach to begin auscultating the thorax?

Accepted Answer

The suggested sequence for a systematic auscultation of the thorax is to begin with the apices.

Question 11

The nurse is obtaining a history of a patient's present illness. The PQRST system is used for the interview. What does the R stand for in this system?

Accepted Answer

In the PQRST system, the R stands for region.

Question 12

During a head-to-toe assessment, the nurse assesses the patient's abdomen. Which area should the nurse assess next?

Accepted Answer

When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.

Question 13

The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?

Accepted Answer

Capillary refill should take fewer than 3 seconds.

Question 14

When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?

Accepted Answer

When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.

Question 15

Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope. What causes the "lubb" sound?

Accepted Answer

The "lubb-dupp" sound of the heart is caused by the closing of the AV and semilunar valves, respectively.

Question 16

A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?

Accepted Answer

Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data.

Question 17

Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine?

Accepted Answer

The sounds indicate the density of the underlying tissue.

Question 18

What should the nurse begin by assessing when performing a head-to-toe assessment?

Accepted Answer

When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.

Question 19

During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated?

Accepted Answer

Crackles are usually heard during inspiration.

Question 20

A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema. When did the edema disappear?

Accepted Answer

The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.

Quiz 12: Physical Assessment

A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective?

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per min-ute?

During a head-to-toe assessment, the nurse assesses the patient's perineal area. Which area should the nurse assess next?

An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique?

The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds?

What is the suggested sequence for a systematic approach to begin auscultating the thorax?

The nurse is obtaining a history of a patient's present illness. The PQRST system is used for the interview. What does the R stand for in this system?

During a head-to-toe assessment, the nurse assesses the patient's abdomen. Which area should the nurse assess next?

The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?

When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?

Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope. What causes the "lubb" sound?

A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?

Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine?

What should the nurse begin by assessing when performing a head-to-toe assessment?

During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated?

A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema. When did the edema disappear?