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Chapter 30: Health Assessment and Physical Examination
Potter et al.: Fundamentals of Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins
to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse
requires the preceptor to intervene?
a. “I will use the information from my assessment to figure out if your
antihypertensive medication is working effectively.”
b. “Nursing assessment data are used only to provide information about the
effectiveness of your medical care.”
c. “Nurses use data from their patient’s physical assessment to determine a patient’s
educational needs.”
d. “Information gained from physical assessment helps nurses better understand
their patients’ emotional needs.”
ANS: B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient’s care, not just the patient’ s medical care.
Assessment data help to evaluate the effectiveness of medications and to determine a patient’s health care needs, including the need
for patient education. Nurses also use assessment data to identify patients’ psychosocial and cultural needs.
DIF: Apply (application) OBJ: Discuss the purposes of physical assessment. TOP: Communication and Documentation MSC: Management of Care
2. Having misplaced a stethoscope, a nurse borrows a colleague’s stethoscope. The nurse next enters the patient’s room and identifies
self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before
auscultating the patient’s lungs. Which critical health assessment step should the nurse have performed?
a. Running warm water over stethoscope
b. Draping stethoscope around the neck
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol
ANS: D
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used. The stetho scope should
be cleaned before use on each patient with isopropyl alcohol benzalkonium, or sodium hypochlorite. Running water over the
stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damage the equipment. Draping the
stethoscope around the neck is not advised.
DIF: Apply (application) OBJ: Make environmental preparations before an examination. TOP: Evaluation MSC: Reduction of Risk Potential
3. A nurse is preparing to perform a complete physical examination on a fragile, older-adult patient diagnosed with bilateral basilar
pneumonia. Which position will the nurse use to facilitate the patient’s breathing?
a. Prone
b. Sims’
c. Supine
d. Lateral recumbent
ANS: C
Supine is the most normally relaxed position. If the patient becomes short of breath easily, raise the head of the bed. Supine
position would be easiest for a weak, older-adult person during the examination. Lateral recumbent and prone positions cause
respiratory difficulty for any patient with respiratory difficulties. Sims’ position is used for assessment of the rectum and the
vagina.
DIF: Apply (application) OBJ: List techniques for preparing a patient physically and psychologically before and during an examination. TOP: Planning MSC: Reduction of Risk Potential
4. A nurse is conducting Weber’s test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient’s forehead.
b. Place a vibrating tuning fork on the patient’s mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient’s degree of joint movement to the normal level.
ANS: A
During Weber’s test (lateralization of sound), the nurse places the vibrating tuning fork in the middle of the patient’s forehead.
During a Rinne test (comparison of air and bone conduction), the nurse places a vibrating tuning fork on the patient’s mastoid
process and compares the length of time air and bone conduction is heard. Comparing the patient’s degree of joint movement to the
normal level is a test for range of motion.
DIF: Apply (application) OBJ: Demonstrate the techniques used with each physical assessment skill. TOP: Implementation MSC: Health Promotion and Maintenance
5. A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for
fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings?
a. Oxygen saturation
b. Liver function test
c. Carbon monoxide
d. Thyroid-stimulating hormone test
ANS: D
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has jaundice. Oxygen saturation
will be used for cyanosis. Cherry-colored lips indicate carbon monoxide poisoning.
DIF: Apply (application) OBJ: Identify ways to use physical assessment skills during routine nursing care. TOP: Planning MSC: Reduction of Risk Potential
6. A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is diagnosed on the basis of t he illness
history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nurse
report?
a. Vesicles
b. Wheals
c. Papules
d. Pustules
ANS: A
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1 cm. Wheals are irregularly
shaped, elevated areas of superficial localized edema that vary in size. They are common with mosquito bites and hives. Papules
are palpable, circumscribed, solid elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to
vesicles, but they are filled with pus and vary in size like acne.
DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Implementation MSC: Physiological Adaptation
7. A school nurse recognizes a belt buckle–shaped ecchymosis on a 7-year-old student. When privately asked about how the injury
occurred, the student described falling on the playground. Which action will the nurse take next?
a. Talk to the principal about how to proceed.
b. Disregard the finding based upon child’s response.
c. Interview the patient in the presence of the teacher.
d. Contact social services and report suspected abuse.
ANS: D
Most states mandate a report to a social service center if nurses suspect abuse or neglect. When abuse is suspected, the nurse
interviews the patient in private, not with a teacher. Observe the behavior of the individual for any signs of frustrati on, explanations
that do not fit his or her physical presentation, or signs of injury. The nurse knows how to proceed and does not need to talk to the
principal about what to do. Disregarding the finding is not advised because victims often will not complain or report that they are in
an abusive situation.
DIF: Apply (application) OBJ: Identify ways to use physical assessment skills during routine nursing care. TOP: Implementation MSC: Management of Care
8. A nurse identifies lice during a child’s scalp assessment. The nurse teaches the parents about hair care. Which information from the
parents indicates the nurse needs to follow up?
a. We will use lindane-based shampoos.
b. We will use the sink to wash hair.
c. We will use a fine-toothed comb.
d. We will use a vinegar hair rinse.
ANS: A
Products containing lindane, a toxic ingredient, often cause adverse reactions; the nurse will need to follow up to corr ect the
misconception. All the rest are correct. Instruct parents who have children with head lice to shampoo thoroughly with pediculicide
(shampoo available at drugstores) in cold water at a basin or sink, comb thoroughly with a fine-toothed comb, and discard the
comb. A dilute solution of vinegar and water helps loosen nits.
DIF: Apply (application) OBJ: Describe physical measurements made in assessing each body system. TOP: Teaching/Learning MSC: Reduction of Risk Potential
13. The school nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a
malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment?
a. Light palpation, deep palpation, and inspection
b. Inspection, light palpation, and deep palpation
c. Auscultation and light palpation
d. Inspection and light palpation
ANS: D
Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of
tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in
the abdomen. Caution is the rule with deep palpation. Deep palpation is performed after light palpation; however, deep palpation is
not performed on a fractured leg. Auscultation is used to evaluate sound and is not used to assess a fractured leg.
DIF: Apply (application) OBJ: Demonstrate the techniques used with each physical assessment skill. TOP: Implementation MSC: Health Promotion and Maintenance
14. The nurse is examining a female presenting with vaginal discharge. Which position will the nurse place the patient for proper
examination?
a. Sitting
b. Lithotomy
c. Knee-chest
d. Dorsal recumbent
ANS: B
Lithotomy is the position for examination of female genitalia. The lithotomy position provides for the maximum exposure of
genitalia and allows the insertion of a vaginal speculum. Sitting does not allow adequate access for speculum insertion and is better
used to visualize upper body parts. Dorsal recumbent is used to examine the head and neck, anterior thorax and lungs, breasts,
axillae, heart, and abdomen. Knee-chest provides maximal exposure of the rectal area but is embarrassing and uncomfortable.
DIF: Understand (comprehension) OBJ: List techniques for preparing a patient physically and psychologically before and during an examination. TOP: Implementation
MSC: Health Promotion and Maintenance
15. On admission, a patient weighs 250 lb. The weight is recorded as 256 lb on the second inpatient day. Which condition will the
nurse assess for in this patient?
a. Anorexia
b. Weight loss
c. Fluid retention
d. Increased nutritional intake
ANS: C
This patient has gained 6 lb in a 24-hour period. A weight gain of 5 lb (2 kg) or more in a day indicates fluid retention problems,
not nutritional intake. A weight loss is considered significant if the patient has lost more than 5% of body weight in a month or 10%
in 6 months. A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as
anorexia.
DIF: Apply (application) OBJ: Identify ways to use physical assessment skills during routine nursing care. TOP: Assessment MSC: Reduction of Risk Potential
16. The patient is a 50-year-old African American male who has come in for a routine annual physical. Which type of preventive
screening does the nurse discuss with the patient?
a. Digital rectal examination of the prostate
b. Complete eye examination every year
c. CA 125 blood test once a year
d. Colonoscopy every 3 years
ANS: A
Recommended preventive screenings include a digital rectal examination of the prostate and prostate-specific antigen test starting
at age 50. CA 125 blood tests are indicated for women at high risk for ovarian cancer. Patients over the age of 65 need to have
complete eye examinations yearly. Colonoscopy every 10 years is recommended in patients 45 years of age and older.
DIF: Apply (application) OBJ: Discuss ways to incorporate health promotion and health teaching into an examination. TOP: Implementation MSC: Health Promotion and Maintenance
17. An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old woman of Chinese descent. Which action
will the nurse do first?
a. Place the patient in the lithotomy position.
b. Drape the patient to enhance patient comfort.
c. Assess the patient’s feelings about the examination.
d. Ask the patient if she would like her mother to be present in the room.
ANS: C
Patients who are Chinese American often believe that examination of the external genitalia is offensive. Before proceeding with the
examination, the nurse first determines how the patient feels about the procedure and explains the procedure to answer any
questions and to help the patient feel comfortable with the assessment. Once the patient is ready to have her external genitalia
examined, the nurse places the patient in the lithotomy position and drapes the patient appropriately. Typically, nurses ask
adolescents if they want a parent present during the examination. The patient in this question is 25 years old; asking i f she would
like her mother to be present is inappropriate.
DIF: Apply (application) OBJ: Discuss how cultural diversity influences a nurse’s approach to and findings from a health assessment. TOP: Implementation MSC: Psychosocial Integrity
18. An older-adult patient is being seen for chronic entropion. Which condition will the nurse assess for in this patient?
a. Ptosis
b. Infection
c. Borborygmi
d. Exophthalmos
ANS: B
The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and cornea. Irritation can lead to infection.
Exophthalmos is a bulging of the eyes and usually indicates hyperthyroidism. An abnormal drooping of the lid over the pupil is
called ptosis. In the older adult, ptosis results from a loss of elasticity that accompanies aging. Hyperactive sounds are loud,
“growling” sounds called borborygmi, which indicate increased GI motility.
DIF: Apply (application) OBJ: Identify ways to use physical assessment skills during routine nursing care. TOP: Assessment MSC: Reduction of Risk Potential
19. During a school physical examination, the nurse reviews the patient’s current medical history. The nurse discovers the p atient has
allergies. Which assessment finding is consistent with allergies?
a. Clubbing
b. Pale nasal mucosa
c. Yellow nasal discharge
d. Puffiness of nasal mucosa
ANS: B
Pale nasal mucosa with clear discharge indicates allergy. Clubbing is due to insufficient oxygenation at the periphery r esulting from
conditions such as chronic emphysema and congenital heart disease; it is noted in the nails. A sinus infection results i n yellowish or
greenish discharge. Habitual use of intranasal cocaine and opioids causes puffiness and increased vascularity of the nas al mucosa.
DIF: Apply (application) OBJ: Identify data to collect from the nursing history before an examination. TOP: Assessment MSC: Health Promotion and Maintenance
20. Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which inspiratory-to-expiratory breath
sounds will the nurse expect to hear?
a. The expiration phase is longer than the inspiration phase.
b. The inspiratory phase lasts exactly as long as the expiratory phase.
c. The expiration phase is 2 times longer than the inspiration phase.
d. The inspiratory phase is 3 times longer than the expiratory phase.
ANS: D
Vesicular breath sounds are normal breath sounds; the inspiratory phase is 3 times longer than the expiratory phase.
Bronchovesicular breath sounds have an inspiratory phase equal to the expiratory phase. Bronchial breath sounds have an
expiration phase longer than the inspiration phase at a 3:2 ratio.
DIF: Apply (application) OBJ: Discuss normal physical findings in a young, middle-aged, and older adult. TOP: Assessment MSC: Health Promotion and Maintenance
21. A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take
when performing an abdominal assessment?
a. Assess the area that is most tender first.
b. Ask the patient about the color of her stools.
c. Recommend that the patient take more laxatives.
d. Avoid sexual references such as possible pregnancy.
ANS: B
Abdominal pain can be related to bowels. If stools are black or tarry (melena), this may indicate gastrointestinal alter ation. The
nurse should caution patients about the dangers of excessive use of laxatives or enemas. There is not enough information about the
abdominal pain to recommend laxatives. Determine if the patient is pregnant and note her last menstrual period. Pregnancy causes
changes in abdominal shape and contour. Assess painful areas last to minimize discomfort and anxiety.
DIF: Apply (application) OBJ: Describe interview techniques used to enhance communication during history taking. TOP: Implementation MSC: Health Promotion and Maintenance
26. During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which
assessment finding will the nurse report to the health care provider?
a. Bruit
b. Thrill
c. Phlebitis
d. Right-sided heart failure
ANS: A
A bruit is the sound of turbulence of blood passing through a narrowed blood vessel and is auscultated as a blowing sound. A bruit
can reflect cardiovascular disease in the carotid artery of middle-aged to older adults. Intensity or loudness is relate d to the rate of
blood flow through the heart or the amount of blood regurgitated. A thrill is a continuous palpable sensation that resembles the
purring of a cat. Jugular venous distention, not bruit, is a possible sign of right-sided heart failure. Some patients with heart disease
have distended jugular veins when sitting. Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel
wall, infection, immobilization, and prolonged insertion of IV catheters. It affects predominantly peripheral veins.
DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Implementation MSC: Management of Care
27. The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap testing and
gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest
need for patient education?
a. 13 years old, nonsmoker, not sexually active
b. 15 years old, social smoker, celibate
c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners
d. 50 years old, stopped smoking 30 years ago, has history of multiple pregnancies
ANS: C
Females considered to be at higher risk include those who smoke, have multiple sex partners, and have a history of sexually
transmitted infections. Of all the assessment findings listed, the 22-year-old smoker with multiple sexual partners has the greatest
number of risk factors for cervical cancer. The other patients are at lower risk: not sexually active, celibate, and do not smoke.
DIF: Analyze (analysis) OBJ: Discuss ways to incorporate health promotion and health teaching into an examination. TOP: Assessment MSC: Health Promotion and Maintenance
28. The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the
patient’s level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion
withdrawal to painful stimuli. Which value will the nurse report for the patient’s Glasgow Coma Scale score?
a. 5
b. 7
c. 9
d. 11
ANS: C
According to the guidelines of the Glasgow Coma Scale, the patient has a score of 9. Opening eyes to pain is 2 points;
inappropriate word use is 3 points; and flexion withdrawal is 4 points. The total for this patient is 2 + 3 + 4 = 9.
DIF: Apply (application) OBJ: Identify ways to use physical assessment skills during routine nursing care. TOP: Assessment MSC: Reduction of Risk Potential
29. While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient’s trunk. What is
the nurse’s next action?
a. Explain that the patient has basal cell carcinoma and should watch for spread.
b. Document cherry angiomas as a normal older adult skin finding.
c. Tell the patient that this is a benign squamous cell carcinoma.
d. Record the presence of petechiae.
ANS: B
The skin is normally free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis
(thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Basal cell carcinoma is most common in sun-exposed
areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body. Squamous cell
carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph
nodes and throughout the body. Report abnormal lesions to the health care provider for further examination. Petechiae are
nonblanching, pinpoint-size, red or purple spots on the skin caused by small hemorrhages in the skin layers.
DIF: Apply (application) OBJ: Discuss normal physical findings in a young, middle-aged, and older adult. TOP: Implementation MSC: Health Promotion and Maintenance
30. A nurse is caring for a group of patients. Which patient will the nurse see first?
a. An adult with an S 4 heart sound
b. A young adult with an S 3 heart sound
c. An adult with vesicular lung sounds in the lung periphery
d. A young adult with bronchovesicular breath sounds between the scapula
posteriorly
ANS: A
A fourth heart sound (S 4 ) occurs when the atria contract to enhance ventricular filling. An S 4 is often heard in healthy older adults,
children, and athletes, but it is not normal in adults. Because S 4 also indicates an abnormal condition, report it to a health care
provider. An S 3 is considered abnormal in adults over 31 years of age but can often be heard normally in children and young adults.
Vesicular lungs sounds in the periphery and bronchovesicular lung sounds in between the scapula are normal findings.
DIF: Analyze (analysis) OBJ: Discuss normal physical findings in a young, middle-aged, and older adult. TOP: Assessment MSC: Management of Care
31. A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment?
a. Uses the bell to listen for lung sounds.
b. Uses the diaphragm to listen for bruits.
c. Uses the diaphragm to listen for bowel sounds.
d. Uses the bell to listen for high-pitched murmurs.
ANS: C
The bell is best for hearing low-pitched sounds such as vascular (bruits) and certain heart sounds (low-pitched murmurs), and the
diaphragm is best for listening to high-pitched sounds such as bowel and lung sounds and high-pitched murmurs.
DIF: Understand (comprehension) OBJ: Demonstrate the techniques used with each physical assessment skill. TOP: Assessment MSC: Health Promotion and Maintenance
32. The nurse is assessing an adult patient’s patellar reflex. Which finding will the nurse record as normal?
a. 1+
b. 2+
c. 3+
d. 4+
ANS: B
Grade reflexes as follows: 0: No response; 1+: Sluggish or diminished; 2+: Active or expected response; 3+: Brisker than expected,
slightly hyperactive; and 4+: Brisk and hyperactive with intermittent or transient clonus.
DIF: Understand (comprehension) OBJ: Discuss normal physical findings in a young, middle-aged, and older adult. TOP: Assessment MSC: Health Promotion and Maintenance
33. A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform
the comprehensive abdominal examination?
a. Percussion, palpation, auscultation
b. Percussion, auscultation, palpation
c. Inspection, palpation, auscultation
d. Inspection, auscultation, palpation
ANS: D
The order of an abdominal examination differs slightly from that of other assessments. Begin with inspection and follow with
auscultation. By using auscultation before palpation, the chance of altering the frequency and character of bowel sounds is
lessened.
DIF: Apply (application) OBJ: Demonstrate the techniques used with each physical assessment skill. TOP: Assessment MSC: Health Promotion and Maintenance
34. The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal?
a. Pulse strength 3
b. 1+ pitting edema
c. Constricting pupils when directly illuminated
d. Hyperactive bowel sounds in all four quadrants
ANS: C
A normal finding is pupils constricting when directly illuminated with a penlight. A pulse strength of 3 indicates a full or increased
pulse; 2 is normal. 1+ pitting edema is abnormal; there should be no edema for a normal finding. Hyperactive bowel sounds are
abnormal and indicate increased GI motility; normal bowel sounds are active.
DIF: Apply (application) OBJ: Discuss normal physical findings in a young, middle-aged, and older adult. TOP: Assessment MSC: Reduction of Risk Potential
39. The nurse is assessing the tympanic membranes of an infant. Which action by the nurse demonstrates proper technique?
a. Pulls the auricle upward and backward.
b. Holds handle of the otoscope between the thumb and little finger.
c. Uses an inverted otoscope grip while pulling the auricle downward and back.
d. Places the handle of the otoscope between the thumb and index finger while
pulling the auricle upward.
ANS: C
Using the inverted otoscope grip while pulling the auricle downward and back is a common approach with infant/child
examinations because it prevents accidental movement of the otoscope deeper into the ear canal, as could occur with an unexpected
pediatric reaction to the ear examination. The other techniques could result in injury to the infant’s tympanic membrane. Insert the
scope while pulling the auricle upward and backward in the adult and older child. Hold the handle of the otoscope in the space
between the thumb and index finger, supported on the middle finger.
DIF: Apply (application) OBJ: Demonstrate the techniques used with each physical assessment skill. TOP: Implementation MSC: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A nurse is assessing a patient’s cranial nerve IX. Which items does the nurse gather before conducting the assessment? ( Select all
that apply. )
a. Vial of sugar
b. Snellen chart
c. Tongue blade
d. Ophthalmoscope
e. Lemon applicator
ANS: A, C, E
Cranial nerve IX is the glossopharyngeal, which controls taste and ability to swallow. The nurse asks the patient to ide ntify sour
(lemon) or sweet (sugar) tastes on the back of the tongue and uses a tongue blade to elicit a gag reflex. Ophthalmoscopes are used
for vision. A Snellen chart is used to test cranial nerve II (optic).
DIF: Apply (application) OBJ: Make environmental preparations before an examination. TOP: Planning MSC: Health Promotion and Maintenance
2. A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? ( Select all that apply. )
a. Orthopnea
b. Nonpalpable lymph nodes
c. Pleural friction rub present
d. Crackles in lower lung lobes
e. Grade 5 muscle function level
f. A 160-degree angle between nail plate and nail
ANS: A, C, D
Abnormal findings will cause a nurse to follow up. Orthopnea is abnormal and indicates cardiovascular or respiratory problems.
Pleural friction rub is abnormal and indicated an inflamed pleura. Crackles are adventitious breath sounds and indicate random,
sudden reinflation of groups of alveoli, indicating disruptive passage of air through small airways. Lymph nodes should be
nonpalpable; palpable lymph nodes are abnormal. Grade 5 muscle function is normal. A 160-degree angle between nail plate and
nail is normal; a larger degree angle is abnormal and indicates clubbing.
DIF: Analyze (analysis) OBJ: Describe physical measurements made in assessing each body system. TOP: Implementation MSC: Reduction of Risk Potential
COMPLETION
1. A nurse is preparing to perform a lung assessment on a patient and discovers through the nursing history the patient smokes. The
nurse figures the pack-years for this patient who has smoked two and a half (2 1/2) packs a day for 20 years. Which value will the
nurse record in the patient’s medical record? Record answer as a whole number. _________ pack-years
ANS:
50
Pack-years = Number of years smoking × Number of packs per day: 20 × 2 = 50.
DIF: Apply (application) OBJ: Identify data to collect from the nursing history before an examination. TOP: Implementation MSC: Reduction of Risk Potential
MATCHING
A nurse is assessing a group of patients. Match the assessment finding the nurse observed to its condition.
a. Lower extremity swollen and warm with normal pulse
b. Neck vein visible when sitting
c. Spoon nails
d. Lower extremity pale and cool with decreased pulse
e. Ringing in ears
f. Swayback
g. Black, tarry stools
1. Koilonychia
2. Venous problems
3. Lordosis
4. Melena
5. Arterial problems
6. Jugular vein distention
7. Tinnitus
- ANS: C DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
- ANS: A DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
- ANS: F DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
- ANS: G DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
- ANS: D DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
- ANS: B DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
- ANS: E DIF: Understand (comprehension) OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: Reduction of Risk Potential
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Exam View - Chapter 30
Course: Fundamentals of Nursing (NUR100)
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University: Fortis College
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Copyright © 2021, Elsevier Inc. All rights reserved. 1
Chapter 30: Health Assessment and Physical Examination
Potter et al.: Fundamentals of Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins
to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse
requires the preceptor to intervene?
a. “I will use the information from my assessment to figure out if your
antihypertensive medication is working effectively.”
b. “Nursing assessment data are used only to provide information about the
effectiveness of your medical care.”
c. “Nurses use data from their patient’s physical assessment to determine a patient’s
educational needs.”
d. “Information gained from physical assessment helps nurses better understand
their patients’ emotional needs.”
ANS: B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient’s care, not just the patient’s medical care.
Assessment data help to evaluate the effectiveness of medications and to determine a patient’s health care needs, including the need
for patient education. Nurses also use assessment data to identify patients’ psychosocial and cultural needs.
DIF: Apply (application) OBJ: Discuss the purposes of physical assessment.
TOP: Communication and Documentation MSC: Management of Care
2. Having misplaced a stethoscope, a nurse borrows a colleague’s stethoscope. The nurse next enters the patient’s room and identifies
self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before
auscultating the patient’s lungs. Which critical health assessment step should the nurse have performed?
a. Running warm water over stethoscope
b. Draping stethoscope around the neck
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol
ANS: D
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used. The stethoscope should
be cleaned before use on each patient with isopropyl alcohol benzalkonium, or sodium hypochlorite. Running water over the
stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damage the equipment. Draping the
stethoscope around the neck is not advised.
DIF: Apply (application)
OBJ: Make environmental preparations before an examination. TOP: Evaluation
MSC: Reduction of Risk Potential
3. A nurse is preparing to perform a complete physical examination on a fragile, older-adult patient diagnosed with bilateral basilar
pneumonia. Which position will the nurse use to facilitate the patient’s breathing?
a. Prone
b. Sims’
c. Supine
d. Lateral recumbent
ANS: C
Supine is the most normally relaxed position. If the patient becomes short of breath easily, raise the head of the bed. Supine
position would be easiest for a weak, older-adult person during the examination. Lateral recumbent and prone positions cause
respiratory difficulty for any patient with respiratory difficulties. Sims’ position is used for assessment of the rectum and the
vagina.
DIF: Apply (application)
OBJ: List techniques for preparing a patient physically and psychologically before and during an examination. TOP: Planning
MSC: Reduction of Risk Potential
4.
A nurse is conducting Weber’s test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient’s forehead.
b. Place a vibrating tuning fork on the patient’s mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient’s degree of joint movement to the normal level.
ANS: A
During Weber’s test (lateralization of sound), the nurse places the vibrating tuning fork in the middle of the patient’s forehead.
During a Rinne test (comparison of air and bone conduction), the nurse places a vibrating tuning fork on the patient’s mastoid
process and compares the length of time air and bone conduction is heard. Comparing the patient’s degree of joint movement to the
normal level is a test for range of motion.
DIF: Apply (application)
OBJ: Demonstrate the techniques used with each physical assessment skill.
TOP: Implementation MSC: Health Promotion and Maintenance
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