NUR 245 Exam II Questions and
Answers
When performing a physical assessment, the first technique the nurse will always use is:
a.
Palpation.
b.
Inspection.
c.
Percussion.
d.
,Auscultation. - ANS: B
The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation.
The skills are performed one at a time and in this order (with the exception of the abdominal
assessment, during which auscultation takes place before palpation and percussion). The assessment of
each body system begins with inspection. A focused inspection takes time and yields a surprising
amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical
assessment? The inspection phase:
a.
Usually yields little information.
b.
Takes time and reveals a surprising amount of information.
c.
May be somewhat uncomfortable for the expert practitioner.
d.
Requires a quick glance at the patients body systems before proceeding with palpation. - ANS: B
,A focused inspection takes time and yields a surprising amount of information. Initially, the examiner
may feel uncomfortable, staring at the person without also doing something. A focused assessment is
significantly more than a quick glance.
3. The nurse is assessing a patients skin during an office visit. What part of the hand and technique
should be used to best assess the patients skin temperature?
a.
Fingertips; they are more sensitive to small changes in temperature.
b.
Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c.
Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
d.
Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its
increased nerve supply in this area. - ANS: B
The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is
thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The
other responses are not useful for palpation.
, . Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and
swelling when the nurse is assessing a patient?
a.
Palpation
b.
Inspection
c.
Percussion
d.
Auscultation - ANS: A
Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision;
percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses
the sense of hearing.
5. The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?
a.
Answers
When performing a physical assessment, the first technique the nurse will always use is:
a.
Palpation.
b.
Inspection.
c.
Percussion.
d.
,Auscultation. - ANS: B
The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation.
The skills are performed one at a time and in this order (with the exception of the abdominal
assessment, during which auscultation takes place before palpation and percussion). The assessment of
each body system begins with inspection. A focused inspection takes time and yields a surprising
amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical
assessment? The inspection phase:
a.
Usually yields little information.
b.
Takes time and reveals a surprising amount of information.
c.
May be somewhat uncomfortable for the expert practitioner.
d.
Requires a quick glance at the patients body systems before proceeding with palpation. - ANS: B
,A focused inspection takes time and yields a surprising amount of information. Initially, the examiner
may feel uncomfortable, staring at the person without also doing something. A focused assessment is
significantly more than a quick glance.
3. The nurse is assessing a patients skin during an office visit. What part of the hand and technique
should be used to best assess the patients skin temperature?
a.
Fingertips; they are more sensitive to small changes in temperature.
b.
Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c.
Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
d.
Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its
increased nerve supply in this area. - ANS: B
The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is
thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The
other responses are not useful for palpation.
, . Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and
swelling when the nurse is assessing a patient?
a.
Palpation
b.
Inspection
c.
Percussion
d.
Auscultation - ANS: A
Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision;
percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses
the sense of hearing.
5. The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?
a.
