Question 1

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 the equipment to reduce their fears.

Question 2

MATCHING
The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation.

-The dorsa (backs)of hands and fingers

Accepted Answer

The answer of MATCHING
The nurse is preparing to palpate the...

Question 3

MATCHING
The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation.

-Fingertips

Accepted Answer

The answer of MATCHING
The nurse is preparing to palpate the...

Question 4

Which of the following statements is true regarding the use of standard precautions in the health care setting?

Accepted Answer

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

Question 5

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 appropriate to the problem.You may return later to complete the assessment after the distress is resolved.

Question 6

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

Accepted Answer

The parent should always be present for the child's feeling of security and to understand normal growth and development.Timing of the examination should be 1 to 2 hours after feeding when the baby is not too drowsy nor too hungry.Infants do not object to being nude;clothing should be removed and a diaper left on a boy.

Question 7

In infants,the nurse knows to elicit the Moro reflex:

Accepted Answer

Elicit the Moro or "startle" reflex at the end of the examination because it may cause the baby to cry.

Question 8

The most important step that the nurse can take to prevent transmission of nosocomial 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 cleansed with an alcohol swab between patients.

Question 9

When examining the aging adult,the nurse should:

Accepted Answer

When examining the aging adult,it is best to arrange the sequence of the examination to allow as few position changes as possible.Physical touch is especially important with the aging person because other senses may be diminished.

Question 10

The nurse is examining a 2-year-old child and asks,"May I listen to your heart now?" Which critique 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 your tummy?"

Question 11

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 variation among teenagers on the rate of growth and development.

Question 12

MATCHING
The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation.

-Base of fingers (metacarpophalangeal joints)or ulnar surface of the hand

Accepted Answer

The answer of MATCHING
The nurse is preparing to palpate the...

Question 13

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

Accepted Answer

The bell of the stethoscope is best for soft,low-pitched sounds such as extra heart sounds or murmurs.

Question 14

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

Accepted Answer

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

Question 15

During an examination of a patient's abdomen,the nurse notes that the abdomen is rounded and firm to the touch.During percussion,the nurse notes a drum-like quality of the sound across the quadrants.This type of sound indicates:

Accepted Answer

A musical or drum-like sound (tympany)is the sound heard when percussion occurs over air-filled viscus,such as the stomach or intestines.

Question 16

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

Accepted Answer

Sitting on the parent's lap is the best place to examine the toddler.Toddlers understand symbols,so a security object is helpful.Initially,focus more on the parent.This allows the child to gradually adjust and become familiar with you.A 2-year-old does not like to take off his or her clothes.Have the parent undress one body part at a time.

Question 17

MATCHING
The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation.

-A grasping action of the fingers and thumb

Accepted Answer

A grasping action of the fingers and thumb is best for detecting the shape and consistency of a mass in the axilla.

Answer: B
 A light palpation with the fingertips is best for evaluating the skin texture over the abdomen.

Answer: C
 The back of the hand is used to determine the temperature of the patient's skin as it is more sensitive to temperature changes.

Answer: D
 The ulnar side of the hand is best for detecting vibration over the thorax and abdomen.

Question 18

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

Accepted Answer

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

Quiz 8: Assessment Techniques and the Clinical Setting

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?

MATCHING The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation. -The dorsa (backs) of hands and fingers

MATCHING The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation. -Fingertips

Which of the following statements is true regarding the use of standard precautions in the health care setting?

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

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

In infants,the nurse knows to elicit the Moro reflex:

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

When examining the aging adult,the nurse should:

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

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

MATCHING The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation. -Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand

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

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

During an examination of a patient's abdomen,the nurse notes that the abdomen is rounded and firm to the touch.During percussion,the nurse notes a drum-like quality of the sound across the quadrants.This type of sound indicates:

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

MATCHING The nurse is preparing to palpate the thorax and abdomen of a patient.For each description listed below,specify the appropriate part of the hand that should be used for palpation. -A grasping action of the fingers and thumb

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