Question 1

A nurse is preparing to assess a patient's ability to detect vibrations. Which piece of equipment is appropriate for this assessment?
A) Reflex hammer
B) Tuning fork
C) Goniometer
D) Monofilament

Accepted Answer

The tuning fork is used to assess the patient's ability to detect vibration. A reflex hammer is used to test for deep tendon reflexes. A goniometer is used to measure the degrees of flexion and extension of a joint. A monofilament is used to test for sensation on the lower extremities.

Question 2

To test deep tendon reflexes, the nurse uses which instrument?
A) Goniometer
B) Calipers
C) Reflex hammer
D) Monofilament

Accepted Answer

A reflex hammer is used to test deep tendon reflexes. A monofilament is used to test for sensation on the lower extremities. Calipers are used to measure thickness of subcutaneous tissue to estimate the amount of body fat. A monofilament is used to test for sensation on the lower extremities.

Question 3

What are characteristics of an audioscope?
A) Screens for hearing ability
B) Allows visualization into the ear canal
C) Must be calibrated before use
D) Uses vibration to estimate hearing loss

Accepted Answer

An audioscope screens for hearing ability. The otoscope allows inspection of the ear canal. Calibration is unnecessary. An audioscope needs batteries that are charged. The tuning fork is the tool that uses vibration to detect hearing loss.

Question 4

When does a nurse choose to use skinfold calipers when collecting assessment data?
A) Calculating the patient's body mass index
B) Inspecting the patient's skin
C) Determining the amount of the patient's lean body tissue
D) Estimating the amount of the patient's body fat

Accepted Answer

Estimating the amount of the patient's body fat is the purpose of using skin calipers. Body mass index is a formula for determining obesity that is calculated by dividing a person's weight in kilograms by the height in meters. Calipers estimate body fat. They are not needed to inspect skin. There is no specific method to determine the amount of lean body tissue.

Question 5

A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which instrument/tool does the nurse use to measure the degree of flexion and extension of the patient's knee joints?
A) Calipers
B) Ruler or tape measure
C) Goniometer
D) Doppler

Accepted Answer

A goniometer is used to measure the degree of flexion and extension of a joint. Calipers are used to estimate the amount of body fat. A ruler or tape measure cannot accurately measure the degree of flexion and extension of joints. Doppler is used to detect the presence of pulses.

Question 6

A patient with type 2 diabetes mellitus has an infected lesion on his foot. During the history of his present illness, he reports, "I had a cut on my foot, but I did not even feel it." What equipment does the nurse use to gather more data about his foot?
A) A Wood lamp
B) Transilluminator
C) Monofilament
D) Reflex hammer

Accepted Answer

A monofilament is used to test for sensation on the lower extremities. Because this patient could not feel the cut on his foot, perhaps he has lost sensation. A Wood lamp is used to detect fungal infection on the skin. A transilluminator differentiates the characteristics of tissue, fluid, and air within a specific body cavity. A reflex hammer is used to test for deep tendon reflexes.

Question 7

A patient is complaining of pain over the maxillary sinuses. Which device does the nurse use to determine if there is air or fluid in the patient's sinuses?
A) Magnification device
B) Transilluminator
C) Monofilament
D) Wood lamp

Accepted Answer

A transilluminator disseminates its light source under the surface of the skin to determine if the areas under the surface, such as the sinuses, are filled with air, fluid, or tissue. A magnification device helps visualize the tissue, but will not determine if sinuses are filled with air or fluid. A monofilament is used to test for sensation on the lower extremities. A Wood lamp is used to detect fungal infections.

Question 8

A nurse suspects that a large skin lesion on the patient's forearm is a fungal infection. Which device does the nurse use to confirm his suspicion?
A) Pen light
B) Magnification device
C) Transilluminator
D) Wood lamp

Accepted Answer

Skin lesions caused by a fungal infection exhibit a fluorescent yellow-green or blue- green color when examined with a Wood lamp. A pen light is used to highlight a lesion for inspection, but will not determine if it is caused by a fungus. A magnification device helps visualize the lesion, but will not determine if it is caused by a fungus. A transilluminator disseminates its light source under the surface of the skin to determine if the area under the surface is filled with air, fluid, or tissue.

Question 9

When does a nurse use a Pederson or Graves speculum for examination of a patient?
A) To inspect the external ear
B) To assess the vaginal canal
C) To inspect nasal passages
D) To assess the oropharynx

Accepted Answer

The vaginal canal and cervix are inspected using a Pederson or Graves speculum or a pediatric or virginal speculum. The external ear is inspected using an otoscope. The nasal passages are inspected using a nasal speculum. The oropharynx is inspected using a tongue blade and penlight.

Question 10

A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next?
A) Document that the dorsalis pedis pulses are not palpable.
B) Have the patient stand and try again to palpate the pulses.
C) Use a Doppler to detect the presence of the pulses.
D) Palpate the dorsalis pedis pulses using the ulnar surface of the hand.

Accepted Answer

Use a Doppler to detect the presence of the pulses. The Doppler uses ultrasonic waves to detect difficult-to-hear vascular sounds, such as peripheral pulses. Document that the dorsalis pedis pulses are not palpable. Although the pulse may not be palpable, the nurse always tries a Doppler to determine if the pulse can be heard, even when it cannot be felt. Have the patient stand and try again to palpate the pulses. Changing positions will not facilitate palpation of a pulse. Palpate the dorsalis pedis pulses using the ulnar surface of the hand. The ulnar surface of the hand is used to palpate for vibrations rather than pulsations.

Question 11

How does the nurse detect a pulse when using a Doppler?
A) The pulsation is felt.
B) The pulsation is heard.
C) The pulse wave is seen on a screen.
D) The pulse wave is printed out on special paper.

Accepted Answer

A Doppler amplifies sounds difficult to hear with an acoustic stethoscope. A Doppler is used when the pulses cannot be palpated. A Doppler amplifies the sound of the pulsation.

Quiz 3: Techniques and Equipment for Physical Assessment

A nurse is preparing to assess a patient's ability to detect vibrations. Which piece of equipment is appropriate for this assessment?

To test deep tendon reflexes, the nurse uses which instrument?

What are characteristics of an audioscope?

When does a nurse choose to use skinfold calipers when collecting assessment data?

A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which instrument/tool does the nurse use to measure the degree of flexion and extension of the patient's knee joints?

A patient with type 2 diabetes mellitus has an infected lesion on his foot. During the history of his present illness, he reports, "I had a cut on my foot, but I did not even feel it." What equipment does the nurse use to gather more data about his foot?

A patient is complaining of pain over the maxillary sinuses. Which device does the nurse use to determine if there is air or fluid in the patient's sinuses?

A nurse suspects that a large skin lesion on the patient's forearm is a fungal infection. Which device does the nurse use to confirm his suspicion?

When does a nurse use a Pederson or Graves speculum for examination of a patient?

A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next?

How does the nurse detect a pulse when using a Doppler?