NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest2022 / 2023 Rasmussen College

NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank | Questions and Answerswith Rationale • The nurse will use which technique of assessment to determine the presence of crepitus,swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation RAT: Palpation applies the sense of touch to assess texture, temperature, moisture, organlocation and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain. • When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physicalexamination? NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College a. Washing one’s hands after removing gloves is not necessary, as long as the glovesare still intact. b. Hands are washed before and after every physical patient encounter. c. Hands are washed before the examination of each body system to prevent thespread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College concern regarding the spread of infectious diseases. RAT: The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contactwith any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact.Gloves should be worn when potential contact with any body fluids is present. • The nurse is examining a patient’s lower leg and notices a draining ulceration. Which ofthese actions is most appropriate in this situation? a. Washing hands, and contacting the physician b. Continuing to examine the ulceration, and then washing hands c. Washing hands, putting on gloves, and continuing with the examination of theulceration d. Washing hands, proceeding with rest of the physical examination, and thencontinuing with the examination of the leg ulceration RAT: The examiner should wear gloves when the potential contact with any body fluidsis present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College • During the examination, offering some brief teaching about the patient’s body or the examiner’s findings is often appropriate. Which one of these statements by the nurse ismost appropriate? a. “Your atrial dysrhythmias are under control.” b. “You have pitting edema and mild varicosities.” c. “Your pulse is 80 beats per minute, which is within the normal range.” d. “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.” RAT: The sharing of some information builds rapport, as long as the patient is able tounderstand the terminology. • The nurse keeps in mind that the most important reason to share information and to offerbrief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation. b. Examiner to build rapport and to increase the patient’s confidence in him orher. c. Patient understand his or her disease process and treatment modalities. d. Patient identify questions about his or her disease and the potential areas of patienteducation. RAT: Sharing information builds rapport and increases the patient’s confidence in the examiner. It also gives the patient a little more control in a situation during which feelingcompletely helpless is often present. • The nurse is examining an infant and prepares to elicit the Moro NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College reflex at which timeduring the examination? a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. Halfway through the examination RAT: The Moro or startle reflex is elicited at the end of the examination because it maycause the infant to cry. • When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infant’s vital signs. RAT: The parent should always be present to increase the child’s feeling of security and to understand normal growth and development. The timing of the examination should be1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants donot object to being nude; clothing should be removed, but a diaper should be left on a boy. NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College • The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is often used to direct light onto the sinuses. b. Uses a short, broad speculum to help visualize the ear. c. Is used to examine the structures of the internal ear. d. Directs light into the ear canal and onto the tympanic membrane. RAT: The otoscope directs light into the ear canal and onto the tympanic membrane thatdivides the external and middle ear. A short, broad speculum is used to visualize the nares. • An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate thatthe examination is being correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College RAT: The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot oflight is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. • A man is at the clinic for a physical examination. He states that he is “very anxious”about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs until the end of the examination, which allows him timeto become comfortable. RAT: Anxiety can be reduced by an examiner who is confident, selfassured, considerate,and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person’s vital signs, will gradually accustom the person to the examination. • A 6-month-old infant has been brought to the well-child clinic for a check-up. She iscurrently sleeping. What should the nurse do first when beginning the examination? NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant’s hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of theexamination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the mostaccurate assessment of body systems. RAT: When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat areinvasive procedures that should be performed at the end of the examination. • The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope of the earpieces should point posteriorly (toward the occiput). b. Although the stethoscope does not magnify sound, it does block out extraneousroom noise. c. Fit and quality of the stethoscope are not as important as its ability to magnifysound. d. Ideal tubing length should be 22 inches to dampen the distortion of sound. RAT: The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner’s nose. Long tubing will distort sound. NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College The fit and quality of the stethoscope are both important. • The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should be lightly held against the person’s skin to block out low-pitched sounds. d. Should be lightly held against the person’s skin to listen for extra heart sounds andmurmurs. RAT: The diaphragm of the stethoscope is best for listening to highpitched sounds suchas breath, bowel, and normal heart sounds. It should be firmly held against the person’s skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low- pitched sounds such as extra heart sounds or murmurs. • Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurseshould: a. Warm the endpiece of the stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled duringthe examination. c. Ensure that the bell side of the stethoscope is turned to the “on” position. d. Check the temperature of the room, and offer blankets to the patient if he orshe feels cold. NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College RAT: The examination room should be warm. If the patient shivers, then the involuntarymuscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner’s hands, not with water. The nurseshould never listen through a gown. The diaphragm of the stethoscope should be used toauscultate for bowel sounds. • During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank Questions and Answers with Rationale Latest 2022 / 2023 Rasmussen College the sounds across the quadrants. This type of sound indicates: a. Constipation. b. Air-filled areas. c. Presence of a tumor. d. Presence of dense organs. RAT: A musical or drum-like sound (tympany) is heard when percussion occurs over anair-filled viscus, such as the stomach or intestines. • The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The thorax, abdomen, and genitalia are examined before the head. b. Talking about the equipment being used is avoided because doing so may increasethe child’s anxiety. c. The nurse should keep in mind that a child at this age will have a sense ofmodesty. d. The child is asked to undress from the waist up. RAT: A 6-year-old child has a sense of modesty. The child should undress him or herself,leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the child’s head to the toes. • During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. Thenurse should: