PHYSICAL ASSESSMENT PRACTICE
QUESTIONS WITH VERIFIED ANSWERS
The nurse is assessing a postoperative patient for signs of hemorrhage. Which adaptation
is most indicative of shock?
1. Hyperemia
2. Hypotension
3. Irregular pulse
4. Slow respirations - Correct Answers -2. Hypotension
1. During the compensatory stage of shock,
blood is shunted away from, not toward, the
periphery. Hyperemia is an increase in blood
fl ow to an area where the overlying skin
becomes reddened and warm.
2. The circulating blood volume is reduced
by 25% to 35% during the compensatory
stage of shock and 35% to 50% during
the progressive stage of shock as the
peripheral vessels constrict to increase
blood fl ow to vital organs. This shunting of
blood causes hypotension.
3. With shock, the heart rate increases
(tachycardia); it is not irregular. The heart
rate increases during the compensatory stage
of shock to maintain adequate blood fl ow to
body tissues.
,4. During the compensatory stage of shock,
the respiratory rate increases, not decreases,
to maintain adequate oxygenation of body
cells.
The nurse is monitoring the vital signs of a group of patients. When reviewing these
results, the nurse must remember that body temperature usually is at its highest at:
1. 12 AM-2 AM
2. 6 AM-8 AM
3. 4 PM-6 PM
4. 8 PM-10 PM - Correct Answers -4. 8 PM-10 PM
1. The body temperature is on the decline
during this time.
2. The body temperature is just beginning to rise
from its lowest level, which occurs between
4 AM and 6 AM.
3. Although the body temperature is rising, it has
not reached its peak at this time.
4. Diurnal variations (circadian rhythms) vary
throughout the day with the highest body
temperature usually occurring between
8 PM and
When assessing for borborygmi, which physical examination method should the nurse
use?
,1. Auscultation
2. Percussion
3. Inspection
4. Palpation - Correct Answers -1. Auscultation
1. Auscultation is the process of listening
to sounds produced in the body. It is
performed directly by just listening
with the ears or indirectly by using a
stethoscope that amplifi es the sounds and
conveys them to the nurse's ears. Active
intestinal peristalsis causes rumbling,
gurgling, and tinkling abdominal sounds
known as bowel sounds (borborygmi).
2. Percussion may stimulate intestinal motility,
which increases bowel sounds, but it is not
the assessment method used to hear bowel
sounds. Percussion is the act of striking the
body's surface to elicit sounds that provide
information about the size and shape of
internal organs or whether tissue is air-fi lled,
fl uid-fi lled, or solid.
3. Inspection cannot assess bowel sounds.
Inspection uses the naked eye to perform a
visual assessment of the body.
4. Palpation may stimulate intestinal motility,
, which increases bowel sounds, but it is not the
assessment method used to hear bowel sounds.
Palpation is the examination of the body using
the sense of touch.
The nurse plans to take a patient's radial pulse. Which method of examination should
be used by the nurse?
1. Palpation
2. Inspection
3. Percussion
4. Auscultation - Correct Answers -1. Palpation
1. Palpation, the examination of the body
using the sense of touch, is used to obtain
the heart rate at a pulse site. When
measuring a pulse, an artery is compressed
slightly by the fi ngers so that the pulsating
artery is held between the fi ngers and a
bone or fi rm structure.
2. A pulse is not measured by using the sense
of sight. Inspection uses the naked eye to
perform a visual assessment of the body.
3. Percussion cannot measure a pulse. Percussion
is the act of striking the body's surface to elicit
sounds that provide information about the size
and shape of internal organs or whether tissue
QUESTIONS WITH VERIFIED ANSWERS
The nurse is assessing a postoperative patient for signs of hemorrhage. Which adaptation
is most indicative of shock?
1. Hyperemia
2. Hypotension
3. Irregular pulse
4. Slow respirations - Correct Answers -2. Hypotension
1. During the compensatory stage of shock,
blood is shunted away from, not toward, the
periphery. Hyperemia is an increase in blood
fl ow to an area where the overlying skin
becomes reddened and warm.
2. The circulating blood volume is reduced
by 25% to 35% during the compensatory
stage of shock and 35% to 50% during
the progressive stage of shock as the
peripheral vessels constrict to increase
blood fl ow to vital organs. This shunting of
blood causes hypotension.
3. With shock, the heart rate increases
(tachycardia); it is not irregular. The heart
rate increases during the compensatory stage
of shock to maintain adequate blood fl ow to
body tissues.
,4. During the compensatory stage of shock,
the respiratory rate increases, not decreases,
to maintain adequate oxygenation of body
cells.
The nurse is monitoring the vital signs of a group of patients. When reviewing these
results, the nurse must remember that body temperature usually is at its highest at:
1. 12 AM-2 AM
2. 6 AM-8 AM
3. 4 PM-6 PM
4. 8 PM-10 PM - Correct Answers -4. 8 PM-10 PM
1. The body temperature is on the decline
during this time.
2. The body temperature is just beginning to rise
from its lowest level, which occurs between
4 AM and 6 AM.
3. Although the body temperature is rising, it has
not reached its peak at this time.
4. Diurnal variations (circadian rhythms) vary
throughout the day with the highest body
temperature usually occurring between
8 PM and
When assessing for borborygmi, which physical examination method should the nurse
use?
,1. Auscultation
2. Percussion
3. Inspection
4. Palpation - Correct Answers -1. Auscultation
1. Auscultation is the process of listening
to sounds produced in the body. It is
performed directly by just listening
with the ears or indirectly by using a
stethoscope that amplifi es the sounds and
conveys them to the nurse's ears. Active
intestinal peristalsis causes rumbling,
gurgling, and tinkling abdominal sounds
known as bowel sounds (borborygmi).
2. Percussion may stimulate intestinal motility,
which increases bowel sounds, but it is not
the assessment method used to hear bowel
sounds. Percussion is the act of striking the
body's surface to elicit sounds that provide
information about the size and shape of
internal organs or whether tissue is air-fi lled,
fl uid-fi lled, or solid.
3. Inspection cannot assess bowel sounds.
Inspection uses the naked eye to perform a
visual assessment of the body.
4. Palpation may stimulate intestinal motility,
, which increases bowel sounds, but it is not the
assessment method used to hear bowel sounds.
Palpation is the examination of the body using
the sense of touch.
The nurse plans to take a patient's radial pulse. Which method of examination should
be used by the nurse?
1. Palpation
2. Inspection
3. Percussion
4. Auscultation - Correct Answers -1. Palpation
1. Palpation, the examination of the body
using the sense of touch, is used to obtain
the heart rate at a pulse site. When
measuring a pulse, an artery is compressed
slightly by the fi ngers so that the pulsating
artery is held between the fi ngers and a
bone or fi rm structure.
2. A pulse is not measured by using the sense
of sight. Inspection uses the naked eye to
perform a visual assessment of the body.
3. Percussion cannot measure a pulse. Percussion
is the act of striking the body's surface to elicit
sounds that provide information about the size
and shape of internal organs or whether tissue
