2025\2026 A+ Grade
The nurse is preparing to assess a 55-year-old female. Which of the following will the nurse do first?
Inspection
Percussion
Palpation
Auscultation
- correct answer Inspection
Inspection always precedes the other assessment skills and is never rushed. The order of assessment
techniques is: inspection, palpation, percussion, and auscultation, except when assessing the abdomen,
where the techniques are inspection, auscultation, percussion, and palpation.
Nursing Process: Planning
Cognitive Level: Comprehension
Client Need: Physiological Integrity
A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which
assessment technique to find out more information about this complaint?
Inspection
Percussion
Palpation
Auscultation
- correct answer Palpation
Palpation is the use of touch to assess specific body characteristics, which include size, shape, location,
mobility, position, vibration, temperature, texture, moisture, tenderness, and edema. Palpating the
ankle will give the nurse information about tenderness, temperature, mobility, and edema
,characteristics. Visual inspection is also included in the assessment of the ankles, but palpation will yield
the most information. Percussion and auscultation are not techniques used to assess the ankles.
Nursing Process: Assessment
Cognitive Level: Synthesis
Client Need: Physiological Integrity
A client comes into the clinic with acute right lower quadrant abdominal pain. During the abdominal
assessment of this client, the nurse realizes that:
This area should be palpated first.
This area should be palpated last.
This area should be assessed using deep palpation techniques.
This area should not be palpated.
- correct answer This area should be palpated last.
Known-painful areas of the body are usually the last areas to be palpated. Deep palpation should be
used with caution, especially if one suspects that there is inflammation, peritonitis, or ectopic
pregnancy. The area should be assessed using light to moderate palpation.
Nursing Process: Planning
Cognitive Level: Application
Client Need: Physiological Integrity
The nurse is preparing to assess a client with flank pain and discomfort and pink-tinged urine. Which of
the following assessment techniques would be appropriate for the nurse to use?
Direct percussion
Reflexive percussion
Indirect percussion
, Blunt percussion
- correct answer Blunt percussion
Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. With
blunt percussion, the palm of the nondominant hand is flat against the body and a closed fist is used to
strike the hand on the body. Direct percussion is tapping the body directly to examine the sinuses or the
thorax of an infant. Reflexive percussion is not an assessment technique. Indirect percussion is the most
common method used to produce sounds within the body. To perform indirect percussion, the middle
finger of the nondominant hand is placed firmly over the area being examined. The middle finger of the
dominant hand quickly strikes the middle finger of the nondominant hand, producing vibrations and a
sound.
Nursing Process: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone. The
nurse would document this sound as being:
Resonance
Hyperresonance
Tympany
Flatness
- correct answer Tympany
Tympany is a loud, high-pitched, drumlike tone of medium duration commonly heard over the stomach
or intestines. Resonance is a loud, low-pitched sound heard over the lungs. Hyperresonance is a loud,
long sound heard when air is trapped in the lungs. Flatness is a soft, short sound heard over solid tissue
such as bone.
Nursing Process: Assessment
Cognitive Level: Comprehension
Client Need: Physiological Integrity
After auscultating the bowel sounds of a client, the nurse realizes the sounds were long. Which of the
following would be appropriate for the nurse to use to document this finding?