Multiple Choice Exam 1 Nurs600/601
1. The nurse is preparing to perform a physical assessment. Which statement is true
about the inspection phase of the physical assessment?
a. Inspection usually yields little information.
b. Inspection takes time and reveals a surprising amount of information.
c. Inspection may be somewhat uncomfortable for the expert practitioner.
d. Inspection requires a quick glance at the patient's body systems before proceeding
on with palpation. - ANSWER...-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 much more than a "quick glance."
2. The nurse would use bimanual palpation technique in which situation?
a. Palpating the thorax of an infant
b. Palpating the kidneys and uterus
c. Assessing pulsations and vibrations
d. Assessing the presence of tenderness and pain - ANSWER...-ANS: B
Bimanual palpation requires the use of both hands to envelop or capture certain body
parts or organs such as the kidneys, uterus, or adnexa. The other situations are not
appropriate for bimanual palpation.
3. The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue:
a. turgor.
b. texture.
c. density.
d. consistency. - ANSWER...-ANS: C
Percussion yields a sound that depicts the location, size, and density of the underlying
organ. Turgor and texture are assessed with palpation.
4. 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? The nurse:
a. percusses once over each area.
b. lifts the striking finger off quickly after each stroke.
c. strikes with the finger tip, not the finger pad.
d. uses the wrist to make the strikes, not the arm. - ANSWER...-ANS: A
For percussion, the nurse should percuss two times over each location. The striking
finger should be lifted off quickly because a resting finger damps off vibrations. The tip
of the striking finger should make contact, not the pad of the finger. The wrist must be
relaxed, and it is used to make the strikes, not the arm.
, 5. 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 an abnormal finding and refer the patient for additional treatment. -
ANSWER...-ANS: A
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull
sound. The other responses are not correct.
6. The nurse hears bilateral louder, longer, and lower tones when percussing over the
lungs of a 4-year-old child. What should the nurse do next?
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. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the examination. -
ANSWER...-ANS: D
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and
longer in duration are normal over a child's lung.
7. A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After putting a call in to the physician and placing the
patient on oxygen, which of these is the best action for the nurse to take when
assessing the patient further?
a. Count the patient's respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations. -
ANSWER...-ANS: B
Percussion is always available, portable, and gives instant feedback regarding changes
in underlying tissue density, which may yield clues of the patient's physical status.
8. The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
a. is used to listen for high-pitched sounds.
b. is used to listen for low-pitched sounds.
c. should be held lightly against the person's skin to block out low-pitched sounds.
d. should be held lightly against the person's skin to listen for extra heart sounds and
murmurs. - ANSWER...-ANS: A
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as
breath, bowel, and normal heart sounds. It should be held firmly against the person's
skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-
pitched sounds such as extra heart sounds or murmurs.
9. The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations?
1. The nurse is preparing to perform a physical assessment. Which statement is true
about the inspection phase of the physical assessment?
a. Inspection usually yields little information.
b. Inspection takes time and reveals a surprising amount of information.
c. Inspection may be somewhat uncomfortable for the expert practitioner.
d. Inspection requires a quick glance at the patient's body systems before proceeding
on with palpation. - ANSWER...-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 much more than a "quick glance."
2. The nurse would use bimanual palpation technique in which situation?
a. Palpating the thorax of an infant
b. Palpating the kidneys and uterus
c. Assessing pulsations and vibrations
d. Assessing the presence of tenderness and pain - ANSWER...-ANS: B
Bimanual palpation requires the use of both hands to envelop or capture certain body
parts or organs such as the kidneys, uterus, or adnexa. The other situations are not
appropriate for bimanual palpation.
3. The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue:
a. turgor.
b. texture.
c. density.
d. consistency. - ANSWER...-ANS: C
Percussion yields a sound that depicts the location, size, and density of the underlying
organ. Turgor and texture are assessed with palpation.
4. 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? The nurse:
a. percusses once over each area.
b. lifts the striking finger off quickly after each stroke.
c. strikes with the finger tip, not the finger pad.
d. uses the wrist to make the strikes, not the arm. - ANSWER...-ANS: A
For percussion, the nurse should percuss two times over each location. The striking
finger should be lifted off quickly because a resting finger damps off vibrations. The tip
of the striking finger should make contact, not the pad of the finger. The wrist must be
relaxed, and it is used to make the strikes, not the arm.
, 5. 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 an abnormal finding and refer the patient for additional treatment. -
ANSWER...-ANS: A
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull
sound. The other responses are not correct.
6. The nurse hears bilateral louder, longer, and lower tones when percussing over the
lungs of a 4-year-old child. What should the nurse do next?
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. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the examination. -
ANSWER...-ANS: D
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and
longer in duration are normal over a child's lung.
7. A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After putting a call in to the physician and placing the
patient on oxygen, which of these is the best action for the nurse to take when
assessing the patient further?
a. Count the patient's respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations. -
ANSWER...-ANS: B
Percussion is always available, portable, and gives instant feedback regarding changes
in underlying tissue density, which may yield clues of the patient's physical status.
8. The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
a. is used to listen for high-pitched sounds.
b. is used to listen for low-pitched sounds.
c. should be held lightly against the person's skin to block out low-pitched sounds.
d. should be held lightly against the person's skin to listen for extra heart sounds and
murmurs. - ANSWER...-ANS: A
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as
breath, bowel, and normal heart sounds. It should be held firmly against the person's
skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-
pitched sounds such as extra heart sounds or murmurs.
9. The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations?
