Assessment Q&A | Nursing
1. A nurse is preparing to conduct a comprehensive health history. Which of
the following is the primary purpose of obtaining this data?
A) To establish a trusting nurse-patient relationship
B) To identify actual and potential health problems
C) To complete the admission process efficiently
D) To determine the patient's financial status
Correct Answer: To identify actual and potential health problems
Rationale: The comprehensive health history is the foundation of the nursing
assessment. Its primary purpose is to collect subjective data that helps the
nurse identify the patient's current health status, risk factors, and potential
health problems, thereby guiding subsequent physical examination and care
planning.
2. Which of the following represents the correct sequence of the six phases
of the nursing process?
A) Assessment, Diagnosis, Outcome Identification, Planning, Implementation,
Evaluation
B) Assessment, Planning, Diagnosis, Outcome Identification, Implementation,
Evaluation
C) Diagnosis, Assessment, Outcome Identification, Planning, Implementation,
Evaluation
D) Assessment, Diagnosis, Planning, Outcome Identification, Implementation,
Evaluation
Correct Answer: Assessment, Diagnosis, Outcome Identification, Planning,
Implementation, Evaluation
,Rationale: The nursing process is a systematic, patient-centered framework
consisting of six sequential steps: Assessment (data collection), Diagnosis
(analysis), Outcome Identification (goal setting), Planning (intervention
selection), Implementation (carrying out the plan), and Evaluation
(determining effectiveness).
3. 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.
4. 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.
5. 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.
6. 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 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.
7. 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.
8. 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