Chapter 16: Health Assessment and Physical Examination

Chapter 16: Health Assessment and Physical Examination

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during inspiration and expiration. These sounds can best be described as which of the following?

ANS:   B

Rhonchi are loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration. They may be cleared by coughing. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Moist crackles are lower, more moist sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. A pleural friction rub has a dry, grating quality heard during inspiration; does not clear with coughing; heard loudest over lower lateral anterior surface.

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    344

OBJ:    Use physical assessment techniques and skills during routine nursing care.

TOP:    Nursing Process: Assessment            MSC:   NCLEX: Management of Care

2. The nursing student is performing a physical examination on a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain. When would be the most appropriate time in the examination to palpate the patient’s abdomen?

ANS:   A

Because palpation involves the use of the hands to touch body parts and make sensitive assessments, palpate tender areas last. Palpation typically occurs right after inspection. When examining the abdomen, however, palpation occurs after auscultation. Palpate the abdomen for tenderness, distention, or masses.

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    317

OBJ:    Describe the techniques used with each physical assessment skill.

TOP:    Nursing Process: Implementation      MSC:   NCLEX: Basic Care and Comfort

3. The registered nurse is precepting a first-year nursing student. She is demonstrating how to appropriately auscultate. Auscultation is defined as which of the following?

ANS:   A

Auscultation is listening for sounds produced by the body. Percussion involves tapping the body with the fingertips to produce a vibration that travels through body tissues. Olfaction, or smelling, helps to detect abnormalities not recognized by other means. Unusual smells lead to detection of serious abnormalities. Palpation involves the use of the hands to touch body parts and make sensitive assessments.

PTS:    1                      DIF:    Cognitive Level: Remembering (Knowledge)

REF:    317 | 318

OBJ:    Describe the techniques used with each physical assessment skill.

TOP:    Nursing Process: Assessment            MSC:   NCLEX: Basic Care and Comfort

4. A patient is being seen in the health clinic for abdominal pain. The nurse will be doing a physical assessment. After using light palpation to examine the patient, the nurse uses deep palpation. With deep palpation the nurse does which of the following?

ANS:   D

After light palpation, use deeper palpation to examine the condition of organs. Depress the area you are examining deeply and evenly. Caution is the rule. To avoid injuring a patient, do not try deep palpation without clinical supervision. Apply deep palpation with one hand or both hands (bimanually). Bimanual palpation involves one hand placed over the other while applying pressure. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses.

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    317

OBJ:    Describe the techniques used with each physical assessment skill.

TOP:    Nursing Process: Implementation       MSC:   NCLEX: Basic Care and Comfort