MULTIPLE CHOICE EXAM 1
NURS600/601 WITH CORRECT
ANSWERS (GRADED A+)
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.
11. The nurse is preparing to perform a physical assessment. The correct action by
the nurse is reflected by which statement? The nurse:
a. performs the examination from the left side of the bed.
b. examines tender or painful areas first to help relieve the patient's anxiety.
c. follows the same examination sequence regardless of the patient's age or
condition.
d. organizes the assessment so that the patient does not change positions too often.
- ANSWER-ANS: D
The steps of the assessment should be organized so that the patient does not
change positions too often. The sequence of the steps of the assessment may differ
depending on the age of the person and the examiner's preference. Tender or
painful areas should be assessed last.
12. During the examination, it is often appropriate to offer some brief teaching about
the patient's body or the examiner's findings. Which of these statements by the nurse
is most appropriate?
a. "Your atrial dysrhythmias are under control."
NURS600/601 WITH CORRECT
ANSWERS (GRADED A+)
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.
11. The nurse is preparing to perform a physical assessment. The correct action by
the nurse is reflected by which statement? The nurse:
a. performs the examination from the left side of the bed.
b. examines tender or painful areas first to help relieve the patient's anxiety.
c. follows the same examination sequence regardless of the patient's age or
condition.
d. organizes the assessment so that the patient does not change positions too often.
- ANSWER-ANS: D
The steps of the assessment should be organized so that the patient does not
change positions too often. The sequence of the steps of the assessment may differ
depending on the age of the person and the examiner's preference. Tender or
painful areas should be assessed last.
12. During the examination, it is often appropriate to offer some brief teaching about
the patient's body or the examiner's findings. Which of these statements by the nurse
is most appropriate?
a. "Your atrial dysrhythmias are under control."
