NR 509 / NR509 w eek 2 Exam w ith |! |! |! |! |! |! |! |!
ver ifi ed solu tions |!
When performing a physical assessment, the first technique the nurse will
|! |! |! |! |! |! |! |! |! |! |!
always use |! |!
A. Palpation
|! |!
B. Inspection
|! |!
C. Percussion
|! |!
D. Auscultation - Correct answer ✔B. Inspection
|! |! |! |! |! |!
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 patient's body systems before proceeding
|! |! |! |! |! |! |! |! |! |! |! |!
with palpation - Correct answer ✔B. Takes time and reveals a surprising
|! |! |! |! |! |! |! |! |! |! |! |!
amount of information |! |!
The nurse is assessing a patient's skin during an office visit. What part of the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
hand and technique should be used to best assess the patient's 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. -
|! |! |! |! |! |! |! |! |! |! |! |!
Correct answer ✔B. Dorsal surface of the hand; the skin is thinner on this
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
surface than on the palms |! |! |! |!
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 - Correct answer ✔A. Palpation
|! |! |! |! |! |!
The nurse is preparing to assess a patient's abdomen by palpation. How
|! |! |! |! |! |! |! |! |! |! |! |!
should the nurse proceed? |! |! |!
A. Palpation of reportedly tender areas are avoided because palpation in these
|! |! |! |! |! |! |! |! |! |! |!
areas may cause pain
|! |! |! |!
B. Palpating a tender area is quickly performed to avoid any discomfort that
|! |! |! |! |! |! |! |! |! |! |! |! |!
the patient may experience
|! |! |!
C. The assessment begins with deep palpation, while encouraging the patient
|! |! |! |! |! |! |! |! |! |! |!
to relax and to take deep breaths.
|! |! |! |! |! |!
D. The assessment begins with light palpation to detect surface characteristics
|! |! |! |! |! |! |! |! |! |!
and to accustom the patient to being touched. - Correct answer ✔D. The
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
,assessment begins with light palpation to detect surface characteristics and to
|! |! |! |! |! |! |! |! |! |! |!
accustom the patient to being touched.
|! |! |! |! |!
The nurse would use bimanual palpation technique in which situation?
|! |! |! |! |! |! |! |! |!
A. Palpating the thorax of an infant
|! |! |! |! |! |!
B. Palpating the kidneys and the uterus
|! |! |! |! |! |!
C. Assessing pulsations and vibrations
|! |! |! |!
D. Assessing the presence of tenderness and pain - Correct answer ✔B.
|! |! |! |! |! |! |! |! |! |! |! |!
Palpating the kidneys and the uterus
|! |! |! |! |!
The nurse is preparing to percuss the abdomen of a patient. The purpose of
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
the percussion is to assess the ___________ of the underlying tissue.
|! |! |! |! |! |! |! |! |! |!
A. Turgor
|!
B. Texture
|!
C. Density
|!
D. Consistency - Correct answer ✔C. Density
|! |! |! |! |! |!
The nurse is reviewing percussion techniques with a newly graduated nurse.
|! |! |! |! |! |! |! |! |! |! |!
Which technique, if used by the new nurse, indicates that more review is
|! |! |! |! |! |! |! |! |! |! |! |! |!
needed?
A. Percussing once over each area
|! |! |! |! |! |!
B. Quickly lifting be striking finger after each stroke
|! |! |! |! |! |! |! |! |!
C. Striking with the fingertip, not the finger pad
|! |! |! |! |! |! |! |! |!
D. Using the wrist to make the strikes, not the arm - Correct answer ✔A.
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
Percussing once over each area |! |! |! |!
, When percussing over the liver of a patient, the nurse notices a dull sound.
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
The nurse should:
|! |!
A. Consider this a normal finding
|! |! |! |! |!
B. Palpate this area for an underlying mass
|! |! |! |! |! |! |!
C. Reposition the hands, and attempt to percuss in this area again
|! |! |! |! |! |! |! |! |! |! |!
D. Consider this finding abnormal, and refer the patient for additional
|! |! |! |! |! |! |! |! |! |! |!
treatment - Correct answer ✔A. Consider this a normal finding
|! |! |! |! |! |! |! |! |!
The nurse is unable to identify any changes in sound when percussing over
|! |! |! |! |! |! |! |! |! |! |! |! |!
the abdomen of an obese patient. What should the nurse do next?
|! |! |! |! |! |! |! |! |! |! |!
A. Ask the patient to take deep breaths to relax the abdominal musculature
|! |! |! |! |! |! |! |! |! |! |! |!
B. Consider this finding as normal and proceed with the abdominal
|! |! |! |! |! |! |! |! |! |! |!
assessment
C. Increase the amount of strength used when attempting to percuss over the
|! |! |! |! |! |! |! |! |! |! |! |! |!
abdomen
D. Decrease the amount of strength used when attempting to percuss over the
|! |! |! |! |! |! |! |! |! |! |! |!
abdomen. - Correct answer ✔C. Increase the amount of strength used when
|! |! |! |! |! |! |! |! |! |! |! |! |!
attempting to percuss over the abdomen |! |! |! |! |!
The nurse hears bilateral loud, long and low tones when percussing over the
|! |! |! |! |! |! |! |! |! |! |! |! |!
lungs of a 4 year old child. The nurse should
|! |! |! |! |! |! |! |! |! |!
A. Palpate over the area for increased pain and tenderness
|! |! |! |! |! |! |! |! |!
B. Ask the child to take shallow breaths and percuss over the area again
|! |! |! |! |! |! |! |! |! |! |! |! |!
C. Immediately refer the child because of an increased amount of air in the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
lungs
ver ifi ed solu tions |!
When performing a physical assessment, the first technique the nurse will
|! |! |! |! |! |! |! |! |! |! |!
always use |! |!
A. Palpation
|! |!
B. Inspection
|! |!
C. Percussion
|! |!
D. Auscultation - Correct answer ✔B. Inspection
|! |! |! |! |! |!
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 patient's body systems before proceeding
|! |! |! |! |! |! |! |! |! |! |! |!
with palpation - Correct answer ✔B. Takes time and reveals a surprising
|! |! |! |! |! |! |! |! |! |! |! |!
amount of information |! |!
The nurse is assessing a patient's skin during an office visit. What part of the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
hand and technique should be used to best assess the patient's 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. -
|! |! |! |! |! |! |! |! |! |! |! |!
Correct answer ✔B. Dorsal surface of the hand; the skin is thinner on this
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
surface than on the palms |! |! |! |!
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 - Correct answer ✔A. Palpation
|! |! |! |! |! |!
The nurse is preparing to assess a patient's abdomen by palpation. How
|! |! |! |! |! |! |! |! |! |! |! |!
should the nurse proceed? |! |! |!
A. Palpation of reportedly tender areas are avoided because palpation in these
|! |! |! |! |! |! |! |! |! |! |!
areas may cause pain
|! |! |! |!
B. Palpating a tender area is quickly performed to avoid any discomfort that
|! |! |! |! |! |! |! |! |! |! |! |! |!
the patient may experience
|! |! |!
C. The assessment begins with deep palpation, while encouraging the patient
|! |! |! |! |! |! |! |! |! |! |!
to relax and to take deep breaths.
|! |! |! |! |! |!
D. The assessment begins with light palpation to detect surface characteristics
|! |! |! |! |! |! |! |! |! |!
and to accustom the patient to being touched. - Correct answer ✔D. The
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
,assessment begins with light palpation to detect surface characteristics and to
|! |! |! |! |! |! |! |! |! |! |!
accustom the patient to being touched.
|! |! |! |! |!
The nurse would use bimanual palpation technique in which situation?
|! |! |! |! |! |! |! |! |!
A. Palpating the thorax of an infant
|! |! |! |! |! |!
B. Palpating the kidneys and the uterus
|! |! |! |! |! |!
C. Assessing pulsations and vibrations
|! |! |! |!
D. Assessing the presence of tenderness and pain - Correct answer ✔B.
|! |! |! |! |! |! |! |! |! |! |! |!
Palpating the kidneys and the uterus
|! |! |! |! |!
The nurse is preparing to percuss the abdomen of a patient. The purpose of
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
the percussion is to assess the ___________ of the underlying tissue.
|! |! |! |! |! |! |! |! |! |!
A. Turgor
|!
B. Texture
|!
C. Density
|!
D. Consistency - Correct answer ✔C. Density
|! |! |! |! |! |!
The nurse is reviewing percussion techniques with a newly graduated nurse.
|! |! |! |! |! |! |! |! |! |! |!
Which technique, if used by the new nurse, indicates that more review is
|! |! |! |! |! |! |! |! |! |! |! |! |!
needed?
A. Percussing once over each area
|! |! |! |! |! |!
B. Quickly lifting be striking finger after each stroke
|! |! |! |! |! |! |! |! |!
C. Striking with the fingertip, not the finger pad
|! |! |! |! |! |! |! |! |!
D. Using the wrist to make the strikes, not the arm - Correct answer ✔A.
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
Percussing once over each area |! |! |! |!
, When percussing over the liver of a patient, the nurse notices a dull sound.
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
The nurse should:
|! |!
A. Consider this a normal finding
|! |! |! |! |!
B. Palpate this area for an underlying mass
|! |! |! |! |! |! |!
C. Reposition the hands, and attempt to percuss in this area again
|! |! |! |! |! |! |! |! |! |! |!
D. Consider this finding abnormal, and refer the patient for additional
|! |! |! |! |! |! |! |! |! |! |!
treatment - Correct answer ✔A. Consider this a normal finding
|! |! |! |! |! |! |! |! |!
The nurse is unable to identify any changes in sound when percussing over
|! |! |! |! |! |! |! |! |! |! |! |! |!
the abdomen of an obese patient. What should the nurse do next?
|! |! |! |! |! |! |! |! |! |! |!
A. Ask the patient to take deep breaths to relax the abdominal musculature
|! |! |! |! |! |! |! |! |! |! |! |!
B. Consider this finding as normal and proceed with the abdominal
|! |! |! |! |! |! |! |! |! |! |!
assessment
C. Increase the amount of strength used when attempting to percuss over the
|! |! |! |! |! |! |! |! |! |! |! |! |!
abdomen
D. Decrease the amount of strength used when attempting to percuss over the
|! |! |! |! |! |! |! |! |! |! |! |!
abdomen. - Correct answer ✔C. Increase the amount of strength used when
|! |! |! |! |! |! |! |! |! |! |! |! |!
attempting to percuss over the abdomen |! |! |! |! |!
The nurse hears bilateral loud, long and low tones when percussing over the
|! |! |! |! |! |! |! |! |! |! |! |! |!
lungs of a 4 year old child. The nurse should
|! |! |! |! |! |! |! |! |! |!
A. Palpate over the area for increased pain and tenderness
|! |! |! |! |! |! |! |! |!
B. Ask the child to take shallow breaths and percuss over the area again
|! |! |! |! |! |! |! |! |! |! |! |! |!
C. Immediately refer the child because of an increased amount of air in the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
lungs
