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NURg2092g/gNUR2092gHealthgAssessmentgExamg2gQuizgBankg|gQuestionsgan
dgAnswersgwithgRationale
• Thegnursegwillgusegwhichgtechniquegofgassessmentgtogdeterminegthegpre
sencegofgcrepitus,gswelling,gandgpulsations?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
RAT:gPalpationgappliesgthegsensegofgtouchgtogassessgtexture,gtemperatur
e,gmoisture,gorganglocationgandgsize,gasgwellgasganygswelling,gvibrationgo
rgpulsation,grigiditygorgspasticity,gcrepitation,gpresencegofglumpsgorgmas
ses,gandgthegpresencegofgtendernessgorgpain.
• Thegnursegisgpreparinggtogusegangotoscopegforgangexamination.gWhichgstatemen
tgisgtrue
regardinggthegotoscope?gThegotoscope:
a. Isgoftengusedgtogdirectglightgontogthegsinuses.
b. Usesgagshort,gbroadgspeculumgtoghelpgvisualizegthegear.
c. Isgusedgtogexaminegthegstructuresgofgtheginternalgear.
d. Directsglightgintogthegeargcanalgandgontogthegtympanicgmembrane.
RAT:gThegotoscopegdirectsglightgintogthegeargcanalgandgontogthegtympa
nicgmembranegthatgdividesgthegexternalgandgmiddlegear.gAgshort,gbroadg
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speculumgisgusedgtogvisualizegthegnares.
• Angexaminergisgusinggangophthalmoscopegtogexaminegagpatient’sgeyes.gT
hegpatientghasgastigmatismgandgisgnearsighted.gThegusegofgwhichgofgthes
egtechniquesgwouldgindicategthatgthegexaminationgisgbeinggcorrectlygperf
ormed?
a. Usinggtheglargegfullgcirclegofglightgwhengassessinggpupilsgthatgaregnotgdilate
d
b. Rotatinggtheglensgselectorgdialgtogthegblackgnumbersgtogcompensategforgasti
gmatism
c. Usinggtheggridgongtheglensgaperturegdialgtogvisualizegthegexternalgstructures
g ofgthegeye
d. Rotatinggtheglensgselectorgdialgtogbringgthegobjectgintogfocus
RAT:gThegophthalmoscopegisgusedgtogexaminegtheginternalgeyegstructure
s.gItgcangcompensategforgnearsightednessgorgfarsightedness,gbutgitgwillgno
tgcorrectgforgastigmatism.gTheggridgisgusedgtogassessgsizegandglocationgofgl
esionsgongthegfundus.gTheglargegfullgspotgofglightgisgusedgtogassessgdilatedg
pupils.gRotatinggtheglensgselectorgdialgbringsgthegobjectgintogfocus.
• Agmangisgatgthegclinicgforgagphysicalgexamination.gHegstatesgthatghegi
sg“veryganxious”gaboutgthegphysicalgexamination.gWhatgstepsgcangth
egnursegtakegtogmakeghimgmoregcomfortable?
a. Appeargunhurriedgandgconfidentgwhengexaminingghim.
b. Staygingthegroomgwhenghegundressesgingcaseghegneedsgassistance.
c. Askghimgtogchangegintogangexaminingggowngandgtogtakegoffghisgundergarm
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ents.
d. Defergmeasuringgvitalgsignsguntilgthegendgofgthegexamination,gwhichg
allowsghimgtimegtogbecomegcomfortable.
RAT:gAnxietygcangbegreducedgbygangexaminergwhogisgconfident,gself-
assured,gconsiderate,gandgunhurried.gFamiliargandgrelativelygnonthreate
ninggactions,gsuchgasgmeasuringgthegperson’sgvitalgsigns,gwillggraduallyga
ccustomgthegpersongtogthegexamination.
• Whengperforminggagphysicalgexamination,gsafetygmustgbegconsideredgt
ogprotectgthegexaminergandgthegpatientgagainstgthegspreadgofginfection.g
Whichgofgthesegstatementsgdescribesgthegmostgappropriategactiongthegn
ursegshouldgtakegwhengperforminggagphysicalgexamination?
a. Washinggone’sghandsgaftergremovinggglovesgisgnotgnecessary,gasglo
nggasgthegglovesgaregstillgintact.
b. Handsgaregwashedgbeforegandgaftergeverygphysicalgpatientgencounter.
c. Handsgaregwashedgbeforegthegexaminationgofgeachgbodygsyste
mgtogpreventgthegspreadgofgbacteriagfromgonegpartgofgthegbodyg
toganother.
d. Glovesgaregworngthroughoutgthegentiregexaminationgtogdemonstrategtogtheg
patient
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concerngregardinggthegspreadgofginfectiousgdiseases.
RAT:gThegnursegshouldgwashghisgorgherghandsgbeforegandgaftergeverygp
hysicalgpatientgencounter;gaftergcontactgwithgblood,gbodygfluids,gsecreti
ons,gandgexcretions;gaftergcontactgwithganygequipmentgcontaminatedgwit
hgbodygfluids;gandgaftergremovingggloves.gHandsgshouldgbegwashedgafte
rgglovesghavegbeengremoved,gevengifgthegglovesgappeargtogbegintact.gGlov
esgshouldgbegworngwhengpotentialgcontactgwithganygbodygfluidsgisgpresen
t.
• Thegnursegisgexamininggagpatient’sglowergleggandgnoticesgagdraininggulc
eration.gWhichgofgthesegactionsgisgmostgappropriategingthisgsituation?
a. Washingghands,gandgcontactinggthegphysician
b. Continuinggtogexaminegthegulceration,gandgthengwashingghands
c. Washingghands,gputtinggonggloves,gandgcontinuinggwithgthegexamin
ationgofgthegulceration
d. Washingghands,gproceedinggwithgrestgofgthegphysicalgexamin
ation,gandgthengcontinuinggwithgthegexaminationgofgthegleggul
ceration
RAT:gThegexaminergshouldgweargglovesgwhengthegpotentialgcontactgwit
hganygbodygfluidsgisgpresent.gIngthisgsituation,gthegnursegshouldgwashghi
sgorgherghands,gputgonggloves,gandgcontinuegexamininggthegulceration.
• Duringgthegexamination,gofferinggsomegbriefgteachinggaboutgthegpatie
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