Assessment Q&A | Nursing
1. A nursing student is learning the four primary physical assessment
techniques. Which technique involves the systematic use of touch to assess
texture, temperature, moisture, and the presence of masses?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Correct Answer: Palpation
Rationale: Palpation uses the hands to apply light or deep touch to assess
various characteristics of the skin and underlying structures, including
texture, temperature, moisture, organ location and size, and the presence of
swelling, masses, or tenderness. It is a systematic technique requiring
practiced skill.
2. A nurse is preparing to perform a physical examination. Which of the
following is the correct order of techniques for the general assessment,
excluding the abdomen?
A) Inspection, palpation, percussion, auscultation
B) Inspection, auscultation, palpation, percussion
C) Palpation, inspection, percussion, auscultation
D) Auscultation, inspection, palpation, percussion
Correct Answer: Inspection, palpation, percussion, auscultation
Rationale: For most body systems, the correct sequence is inspection first,
followed by palpation, percussion, and then auscultation. This order allows
,the examiner to observe without disturbing the area and then systematically
assess deeper structures. The abdominal assessment requires a different
sequence.
3. A nurse is preparing to assess a patient's abdomen. In which order should
the techniques of inspection, palpation, percussion, and auscultation be
performed?
A) Inspection, palpation, percussion, auscultation
B) Inspection, auscultation, percussion, palpation
C) Palpation, auscultation, inspection, percussion
D) Auscultation, inspection, palpation, percussion
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: For abdominal assessment, the correct sequence is inspection
first, followed by auscultation, percussion, and finally palpation. This order is
crucial because palpation and percussion can alter bowel sounds, potentially
leading to inaccurate auscultation findings.
4. A nurse is using the technique of percussion during a physical
examination. What is the primary purpose of this technique?
A) To listen to the sounds of the heart and lungs
B) To visually inspect the patient's body structure
C) To tap the body to produce sounds that indicate the density of underlying
structures
D) To feel for the presence of pulses and skin temperature
Correct Answer: To tap the body to produce sounds that indicate the density
of underlying structures
,Rationale: Percussion involves tapping the body surface with the fingertips or
a reflex hammer to produce sound waves. The resulting sounds (resonance,
hyperresonance, dullness, or flatness) help the examiner assess the size,
location, and density of underlying organs and detect the presence of air,
fluid, or solid masses.
5. When using a stethoscope to listen to body sounds, the nurse is
performing which assessment technique?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Correct Answer: Auscultation
Rationale: Auscultation is the technique of listening to sounds produced
within the body using a stethoscope. It is primarily used to assess the heart,
lungs, and abdomen, listening for normal and abnormal sounds such as heart
murmurs, breath sounds, and bowel sounds.
6. A nurse is assessing a patient's skin and notes a lesion that is flat, non-
palpable, and less than 1 cm in diameter. This type of lesion is best
described as a:
A) Papule
B) Macule
C) Nodule
D) Vesicle
Correct Answer: Macule
, Rationale: A macule is a flat, circumscribed area of color change that is less
than 1 cm in diameter and is not raised or palpable. Examples include
freckles, flat moles, and petechiae. A papule is raised, a nodule is larger and
deeper, and a vesicle is a fluid-filled blister.
7. A nurse observes a raised, solid lesion on a patient's skin that is less than
1 cm in diameter. This type of lesion is documented as a:
A) Macule
B) Papule
C) Nodule
D) Wheal
Correct Answer: Papule
Rationale: A papule is a raised, solid, palpable lesion that is less than 1 cm in
diameter. Examples include acne, warts, and some skin tags. A macule is
flat, a nodule is larger (> 1 cm), and a wheal is an edematous, transient
lesion.
8. A nurse is assessing a patient's skin turgor. Which of the following is the
most accurate method to assess skin turgor in an elderly patient?
A) Pinching the skin on the back of the hand
B) Pinching the skin on the sternum or clavicle
C) Pinching the skin on the forehead
D) Pinching the skin on the abdomen
Correct Answer: Pinching the skin on the sternum or clavicle
Rationale: Skin turgor is best assessed by pinching a fold of skin on the
sternum or clavicle, as these areas have less age-related loss of elasticity. In