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1. Which of the following best describes the primary purpose of the general survey
during a physical assessment?
A) To obtain a comprehensive review of all body systems
B) To establish a baseline for vital signs and laboratory values
C) To observe the patient's overall appearance, body structure, mobility, and behavior
D) To identify specific pathological conditions through auscultation
Correct Answer: To observe the patient's overall appearance, body structure,
mobility, and behavior
Rationale: The general survey is the first component of the physical examination,
beginning the moment the nurse meets the patient. It involves observing the
patient's appearance, body structure, mobility, and behavior to form an initial
impression. This information guides the remainder of the focused assessments and
helps identify any immediate concerns.
2. During a comprehensive physical assessment, which technique is performed first
by the nurse?
A) Palpation
B) Percussion
C) Auscultation
D) Inspection
Correct Answer: Inspection
,Rationale: Inspection is the first and most frequently used physical examination
technique, involving a visual examination of the patient's body using the senses of
sight, smell, and hearing. It should always be performed first, before palpation,
percussion, or auscultation, as these other techniques can alter findings.
3. The nurse is assessing a patient's skin during an office visit. What part of the hand
should be used to best assess the patient's skin temperature?
A) Fingertips; they are more sensitive to small changes in temperature
B) Ulnar portion of the hand; increased blood supply in this area enhances
temperature sensitivity
C) Dorsal surface of the hand; the skin is thinner on this surface than on the palms
D) Palmar surface of the hand; this surface is the most sensitive to temperature
variations
Correct Answer: Dorsal surface of the hand; the skin is thinner on this surface than
on the palms
Rationale: The dorsal (back) surface of the hand is the most sensitive part for
assessing temperature because the skin is thinner and has a rich blood supply. The
fingertips are best for fine tactile discrimination, and the ulnar surface is used for
detecting vibration.
4. When performing a physical assessment, the nurse will use the stethoscope to
auscultate body sounds. Which statement is true regarding the stethoscope and its
use?
A) Ideal tubing length should be 22 inches to dampen the distortion of sound
B) Although the stethoscope does not magnify sound, it does block out extraneous
room noise
C) Fit and quality of the stethoscope are not as important as its ability to magnify
sound
, D) Slope of the earpieces should point posteriorly (toward the occiput)
Correct Answer: Although the stethoscope does not magnify sound, it does block
out extraneous room noise
Rationale: A stethoscope does not amplify sound; it simply blocks out ambient room
noise so that internal body sounds are more easily conducted to the examiner's ears.
The earpieces should point forward, and tubing length should be appropriate to
avoid distortion.
5. Before auscultating the abdomen for the presence of bowel sounds, the nurse
should first:
A) Warm the end piece of the stethoscope by placing it in warm water
B) Check the temperature of the room and offer blankets if the patient feels cold
C) Ensure that the bell side of the stethoscope is turned to the "on" position
D) Leave the gown on the patient to ensure they do not get chilled
Correct Answer: Warm the end piece of the stethoscope by placing it in warm water
Rationale: Warming the stethoscope end piece before abdominal auscultation
prevents the patient from experiencing a cold sensation, which can cause muscle
tensing and alter bowel sounds. The diaphragm is typically used for bowel sounds,
not the bell.
6. The nurse is unable to palpate the right radial pulse on a patient. What is the best
action to take?
A) Use a Doppler device to check for pulsations over the area
B) Use a goniometer to measure the pulsations
C) Check for the presence of pulsations with a stethoscope