Deck 8: Physical Examination Techniques

Question 1

The nurse would perform direct auscultation by

A) listening to the patient with the unaided ear from some distance away.
B) using an acoustic stethoscope.
C) using a Doppler.
D) using a digital stethoscope.

Answer 1

listening to the patient with the unaided ear from some distance away.

Question 2

The key factor in avoiding malpractice claims is to

A) address any concerns or protests before the examination.
B) document completely all examinations, procedures, and injuries.
C) establish a trusting and caring relationship.
D) provide appropriate information during each step of the examination process.

Answer 2

establish a trusting and caring relationship.

Question 3

When conducting a physical examination of a client's abdomen,the nurse would perform inspection and auscultation before percussion and palpation for which of the following reasons?

A) This is the usual sequence of conducting a physical examination.
B) Inspection and auscultation are easier to master.
C) Inspection and auscultation provide more useful and reliable information.
D) Percussion and palpation may alter bowel sounds if performed before auscultation.

Answer 3

Percussion and palpation may alter bowel sounds if performed before auscultation.

Question 4

Direct and indirect fist percussions are useful in assessing the

A) change of sound from resonance to dullness.
B) presence of pain indicating inflammation of the organ.
C) presence of deep masses.
D) change of sound from dullness to resonance.

Question 5

When the nurse is performing indirect percussion,the middle finger of the dominant hand,known as the plexor

A) is placed firmly on the location to be percussed.
B) strikes the area to be assessed.
C) delivers a sharp, crisp blow using the fingertip rather than the finger pad.
D) strikes the pleximeter between the distal interphalangeal joint and the fingernail.

Question 6

The recommended sequence for conducting assessment procedures is to progress from

A) one side to the other.
B) the extremities to the trunk.
C) anterior to posterior.
D) the least intrusive to the most intrusive.

Question 7

Deep palpation is more frequently performed for assessment of

A) the abdomen and male and female reproductive organs.
B) muscle guarding.
C) superficial tenderness.
D) the thorax and extremities.

Question 8

Light palpation is performed by placing the finger pads of your dominant hand on the patient's skin and

A) depressing the skin 4-5 cm.
B) holding your hand and forearm at a right angle to the area being assessed.
C) moving the finger pads using gentle circular motions.
D) moving the finger pads from one area to another without allowing the depressed body surface to rebound to its natural position.

Question 9

Inspection is performed by using one's

A) hearing and vision.
B) smell and vision.
C) touch and vision.
D) vision only.

Question 10

The characteristic of percussion sounds that refers to the frequency of the sound's vibrations is

A) duration.
B) intensity.
C) pitch.
D) quality.

Question 11

Light palpation is useful to gain information about the

A) mobility and consistency of organs and masses.
B) position of organs and masses.
C) presence of large masses or fluid.
D) size and shape of organs and masses.

Question 12

The more air-filled a structure is,the

A) higher its pitch, the softer its intensity, and the shorter its duration.
B) higher its pitch, the louder its intensity, and the shorter its duration.
C) lower its pitch, the louder its intensity, and the shorter its duration.
D) lower its pitch, the louder its intensity, and the longer its duration.

Question 13

To perform direct (immediate)percussion,you would make a light tapping motion against the patient's body part being percussed with the

A) finger pad of the index or middle finger of your dominant hand.
B) finger pads of the index and middle fingers of your nondominant hand.
C) percussion hammer.
D) ulnar aspect of the closed fist of your dominant hand.

Question 14

Guidelines for the proper use of the stethoscope include which of the following?

A) The bell should be placed firmly against the skin surface.
B) The earpieces and binaurals should be angled toward your nose.
C) Longer rubber or plastic tubing enhances the body sounds.
D) The diaphragm is used to auscultate low-pitched sounds such as bruits and some heart murmurs.

Question 15

Percussion is a useful examination technique to determine the size,shape,and position of organs as well as to

A) determine the density (air, fluid, or solid) of a structure.
B) detect an abnormal deep mass (over 5 cm deep).
C) listen to body organs to gather information on the patient's clinical status.
D) determine the skin moisture and texture with your hands.

Question 16

The most important infection control practice for the health care provider to follow is

A) environmental control.
B) hand hygiene.
C) wearing gloves.
D) wearing a gown, mask, and eye protection.

Question 17

When the nurse performs indirect fist percussion,the nondominant hand is placed over the area to be examined,with the fingers

A) adjacent to one another in straight alignment with the palm.
B) drawn up in a closed fist.
C) placed with the dorsal side lying on the skin's surface.
D) slightly flexed.

Question 18

A percussion sound that is loud in intensity,moderate to long in duration,low in pitch,and hollow in quality is resonance.Which of the following is an example of where this is heard in the body?

A) gastric air bubble
B) healthy lung tissue
C) over organs (liver)
D) over muscle

Question 19

Which portion of your hand is most sensitive to assessing vibrations such as a cardiac thrill?

A) dorsum of the hand
B) finger pads
C) palmar surface of the fingers at the metacarpophalangeal joints
D) radial surface of the hand at the distal interphalangeal joints

Question 20

The nurse preparing to palpate a patient would begin by

A) not wearing gloves because they can interfere with the ability to accurately feel.
B) avoiding to tell the patient where the nurse will touch so the muscles will not tense up.
C) ensuring that the nurse's fingernails are short to prevent discomfort or injury.
D) telling the patient to hold his breath during the palpation.

Question 21

The nurse preceptor asks a new graduate,"Which of the following items would be considered single-use items according to the CDC? Which response by the new graduate would indicate that further teaching is needed? Select all that apply.

A) Glass thermometer
B) Thermometer probe cover
C) Endoscopes
D) Dressing materials
E) Surgical equipment
F) Urinary catheters

Question 22

Which action by the nurse is likely to be helpful in blocking out extraneous noises while auscultating with a stethoscope?

A) Place the stethoscope on the patient's clothing to avoid contact with the skin which may cause chilling and shivering.
B) Remove dangling necklaces or bracelets that can move during the exam and cause noises that can interfere with the assessment.
C) Shave the area to be auscultated if there is a large quantity of hair.
D) Keep your eyes open to help you isolate the sound.

Question 23

Standard precautions are used to prevent the exchange of ____________________ and ____________________.

Question 24

When preparing a patient for a physical examination,you should

A) ask the patient to void before the assessment.
B) ask the patient to remove all clothes and use a clean sheet as a drape.
C) lower the bed to enhance eye contact and prevent injury.
D) wash the patient's hands to prevent the spread of infection.

Question 25

You are caring for a newly admitted patient and realize that the research has shown that there is an increased risk of contracting Neissera meningitides from respirator secretions during which of the following procedures? Select all that apply.

A) Measuring oral temperature
B) Placing a catheter into epidural spaces
C) Injecting material into epidural spaces
D) Injecting material into subdural spaces
E) Placing a catheter into subdural spaces
F) Measuring pulse rate

Question 26

The physical examination should be conducted from which of the following directions?

A) left to right
B) right to left
C) head to toe
D) toe to head

Question 27

A nursing instructor has completed a lecture on latex allergies.On a quiz,the instructor asks the students,"Which foods do patients have an increased risk of reacting to,when the patient has a latex allergy?" Which answers by the students would indicate to the instructor that further teaching is needed? Select all that apply.

A) Avocados
B) Bananas
C) Chestnuts
D) Kiwi
E) Oranges
F) Potatoes

Question 28

You are using deep palpation to examine a patient's abdomen.At which depth would you palpate?

A) 1-2 cm
B) 2-3 cm
C) 4-5 cm
D) 6-8 cm

Question 29

According to the American Academy of Allergy,Asthma,& Immunology,what percentage of the general population have a latex allergy?

A) 1%
B) 5%
C) 10%
D) 15%

Question 30

Bedridden patients who cannot sit up should be assessed in the ____________________ position.

Question 31

Which of the following golden rules for physical examination decreases the likelihood of forgetting to perform a particular assessment?

A) Always compare the right and left sides of the body for symmetry.
B) Conduct the examination in a systematic fashion each time.
C) Perform the examination in a head-to-toe approach.
D) Stand on the right side of the patient.

Question 32

Which of the following medical products contain latex? Select all that apply.

A) Syringes
B) Thermometers
C) Wound drains
D) Tourniquets
E) Blood pressure cuffs
F) Rubber stoppers on medication vials

Question 33

It is vital that nurses working in outpatient clinics use safe injection practices to prevent spreading infectious agents from patient to patient and from patient to health care providers to prevent the transmission of which of the following?

A) measles and mumps
B) pneumonia and influenza
C) hepatitis B and hepatitis C
D) encephalitis and hepatitis A

Question 34

Which of the following agencies stipulates procedures for the cleaning of areas contaminated with blood or body fluids?

A) ANA
B) CDC
C) NLN
D) OSHA

Question 35

Research has shown an increased risk of contracting Neisseria meningitides from respirator secretions during which of the following procedures?

A) providing a complete bed bath
B) injecting material into epidural spaces
C) examining vaginal or rectal secretions
D) inserting a Foley catheter or rectal tube

Question 36

Which of the following are a manifestation of latex allergy? Select all that apply.

A) Hives
B) Anaphylaxis
C) Wheezing
D) Bruising
E) Allergy to apples and pears
F) Eczematous contact dermatitis

Question 37

Hyperresonance,heard while percussing the lungs,is most likely to be caused by ____________________.

Question 38

With percussion,a high-pitched sound is usually indicative of a(n)____________________ structure.

Question 39

In addition to monitoring of current health problems,establishing a baseline information for future examinations,and validating the complaints that brought the patient to seek health care,the nurse uses the physical examination for which of the following?

A) prescribing medications needed
B) satisfying nurse and patient curiosity
C) establishing patient's ability to pay for care
D) formulating the nursing diagnoses and treatments