Physical Assessment Practice Questions And Answers

The nurse is assessing a postoperative patient for signs of hemorrhage. Which adaptation is most indicative of shock? 1. Hyperemia 2. Hypotension 3. Irregular pulse 4. Slow respirations - ANS 2. Hypotension 1. During the compensatory stage of shock, blood is shunted away from, not toward, the periphery. Hyperemia is an increase in blood fl ow to an area where the overlying skin becomes reddened and warm. 2. The circulating blood volume is reduced by 25% to 35% during the compensatory stage of shock and 35% to 50% during the progressive stage of shock as the peripheral vessels constrict to increase blood fl ow to vital organs. This shunting of blood causes hypotension. 3. With shock, the heart rate increases (tachycardia); it is not irregular. The heart rate increases during the compensatory stage of shock to maintain adequate blood fl ow to body tissues. 4. During the compensatory stage of shock, the respiratory rate increases, not decreases, to maintain adequate oxygenation of body cells. The nurse is monitoring the vital signs of a group of patients. When reviewing these results, the nurse must remember that body temperature usually is at its highest at: 1. 12 AM-2 AM 2. 6 AM-8 AM 3. 4 PM-6 PM 4. 8 PM-10 PM - ANS 4. 8 PM-10 PM 1. The body temperature is on the decline during this time. 2. The body temperature is just beginning to rise from its lowest level, which occurs between 4 AM and 6 AM. 3. Although the body temperature is rising, it has not reached its peak at this time. 4. Diurnal variations (circadian rhythms) vary throughout the day with the highest body temperature usually occurring between 8 PM and When assessing for borborygmi, which physical examination method should the nurse use? 1. Auscultation 2. Percussion 3. Inspection 4. Palpation - ANS 1. Auscultation 1. Auscultation is the process of listening to sounds produced in the body. It is performed directly by just listening with the ears or indirectly by using a stethoscope that amplifi es the sounds and conveys them to the nurse's ears. Active intestinal peristalsis causes rumbling, gurgling, and tinkling abdominal sounds known as bowel sounds (borborygmi). 2. Percussion may stimulate intestinal motility, which increases bowel sounds, but it is not the assessment method used to hear bowel sounds. Percussion is the act of striking the body's surface to elicit sounds that provide information about the size and shape of internal organs or whether tissue is air-fi lled, fl uid-fi lled, or solid. 3. Inspection cannot assess bowel sounds. Inspection uses the naked eye to perform a visual assessment of the body. 4. Palpation may stimulate intestinal motility, which increases bowel sounds, but it is not the assessment method used to hear bowel sounds. Palpation is the examination of the body using the sense of touch. The nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation - ANS 1. Palpation 1. Palpation, the examination of the body using the sense of touch, is used to obtain the heart rate at a pulse site. When measuring a pulse, an artery is compressed slightly by the fi ngers so that the pulsating artery is held between the fi ngers and a bone or fi rm structure. 2. A pulse is not measured by using the sense of sight. Inspection uses the naked eye to perform a visual assessment of the body. 3. Percussion cannot measure a pulse. Percussion is the act of striking the body's surface to elicit sounds that provide information about the size and shape of internal organs or whether tissue is air-fi lled, fl uid-fi lled, or solid. 4. Auscultation is used to obtain an apical, not radial, pulse. Auscultation is the process of listening to sounds produced in the body. It is performed directly by just listening with the ears or indirectly by using a stethoscope that amplifi es the sounds and conveys them to the nurse's ears. Which nursing action is common to all instruments when taking a temperature? 1. Identify that the reading is below 96°F before insertion 2. Wash with cool soap and water after use 3. Place a disposable sheath over the probe 4. Ensure that the instrument is clean - ANS 4. Ensure that the instrument is clean 1. This is not true for all thermometers, such as chemical disposable thermometers, temperature-sensitive tape, and electronic thermometers. This is true for glass/plastic thermometers. 2. This is true only for glass/plastic thermometers.