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1. During a comprehensive physical assessment, the nurse performs the four basic
examination techniques. For which body system does the sequence of techniques
differ from the standard order?
A) Cardiovascular system
B) Respiratory system
C) Abdominal system
D) Neurological system
Correct Answer: Abdominal system
Rationale: The standard order of examination techniques is inspection, palpation,
percussion, and auscultation. However, for the abdomen, the sequence is altered to
inspection, auscultation, percussion, and palpation because manipulating the
abdomen with percussion or palpation can increase peristalsis and alter bowel
sounds, giving a false finding.
2. The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Correct Answer: Palpation
,Rationale: Palpation uses the sense of touch to assess texture, temperature,
moisture, organ location and size, swelling, vibration, pulsation, rigidity, crepitus, and
tenderness. Inspection only allows visual assessment, percussion assesses density,
and auscultation listens for body sounds. Palpation is essential for detecting tactile
changes.
3. A nurse is preparing to use an otoscope for an examination. Which statement is
true regarding the otoscope?
A) It is often used to direct light onto the sinuses
B) It uses a short, broad speculum to help visualize the ear
C) It is used to examine the structures of the internal ear
D) It directs light into the ear canal and onto the tympanic membrane
Correct Answer: It directs light into the ear canal and onto the tympanic membrane
Rationale: An otoscope is used to illuminate and examine the external ear canal and
tympanic membrane, allowing detection of infection, cerumen impaction, or
perforation. A broad speculum is for nasal exams, not the ear. Directing light
accurately ensures visualization of the middle ear structures.
4. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient
has astigmatism and is nearsighted. Which technique would indicate the 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
, Correct Answer: Rotating the lens selector dial to bring the object into focus
Rationale: The ophthalmoscope is used to examine internal eye structures such as
the retina and optic disc. The lens selector dial allows the examiner to adjust for
nearsightedness or farsightedness to bring the image into focus. Astigmatism is not
corrected by this dial. The grid is used for mapping lesions.
5. The nurse is using a stethoscope to auscultate breath sounds. Which statement
about the stethoscope is correct?
A) The stethoscope magnifies body sounds for better hearing
B) The stethoscope blocks out all external sounds
C) The stethoscope blocks extraneous sounds but does not magnify them
D) The stethoscope is most effective when used over clothing
Correct Answer: The stethoscope blocks extraneous sounds but does not magnify
them
Rationale: A stethoscope does not amplify or magnify sound; it simply blocks out
ambient room noise so that internal body sounds are more easily conducted to the
examiner's ears. It should always be placed directly on bare skin, not over clothing, to
prevent friction noise and sound distortion.
6. Which part of the hand is best for assessing the position, shape, and consistency of
an organ or mass?
A) Fingertips
B) Dorsa of the hands
C) Base of the fingers
D) Fingers and thumb