NUR 3121 Health Assessment Unit 2 Exam
UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
When performing a physical assessment, the technique the nurse will always use first is: -
CORRECT ANSWER ANS: inspection.
The skills requisite for the physical examination are inspection, palpation, percussion, and
auscultation. The skills are performed one at a time and in this order (with the exception of
the abdominal assessment, where auscultation takes place before palpation and percussion).
The assessment of each body system begins with inspection. A focused inspection takes time
and yields a surprising amount of information.
The nurse is preparing to perform a physical assessment. Which statement is true about the
inspection phase of the physical assessment? - CORRECT ANSWER ANS: Inspection
takes time and reveals a surprising amount of information.
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."
The nurse is assessing a patient's skin during an office visit. What is the best technique to use
to best assess the patient's skin temperature? Use the: - CORRECT ANSWER ANS:
dorsal surface of the hand because the skin is thinner than on the palms.
The dorsa (backs) of hands and fingers are best for determining temperature because the skin
there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other
responses are not useful for palpation.
Which of these techniques uses the sense of touch to assess texture, temperature, moisture,
and swelling when the nurse is assessing a patient? - CORRECT ANSWER ANS:
Palpation
,Palpation uses the sense of touch to assess the patient for these factors. Inspection involves
vision; percussion assesses through the use of palpable vibrations and audible sounds; and
auscultation uses the sense of hearing.
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse
proceed? - CORRECT ANSWER ANS: Start with light palpation to detect surface
characteristics and to accustom the patient to being touched.
Light palpation is performed initially to detect any surface characteristics and to accustom the
person to being touched. Tender areas should be palpated last, not first.
The nurse would use bimanual palpation technique in which situation? - CORRECT
ANSWER ANS: Palpating the kidneys and uterus
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.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is
to assess the underlying tissue: - CORRECT ANSWER ANS: density.
Percussion yields a sound that depicts the location, size, and density of the underlying organ.
Turgor and texture are assessed with palpation.
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: -
CORRECT ANSWER ANS: percusses once over each area.
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.
,When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
- CORRECT ANSWER ANS: consider this a normal finding.
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound.
The other responses are not correct.
The nurse is unable to identify any changes in sound when percussing over the abdomen of
an obese patient. What should the nurse do next? - CORRECT ANSWER ANS:
Increase the amount of strength used when attempting to percuss over the abdomen.
The thickness of the person's body wall will be a factor. The nurse will need a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the blow
determines the loudness of the note. The other actions are not correct.
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? - CORRECT ANSWER ANS:
Consider this a normal finding for a child this age and proceed with the examination.
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.
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? -
CORRECT ANSWER ANS: Percuss the thorax bilaterally, noting any differences in
percussion tones.
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.
The nurse is teaching a class on basic assessment skills. Which of these statements is true
regarding the stethoscope and its use? - CORRECT ANSWER ANS: The stethoscope
does not magnify sound but does block out extraneous room noise.
, The stethoscope does not magnify sound but does block out extraneous room sounds. The
slope of the earpieces should point forward toward the examiner's nose. Longer tubing will
distort sound. The fit and quality of the stethoscope are important.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm: - CORRECT
ANSWER ANS: is used to listen for high-pitched sounds.
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath,
bowel, and normal heart sounds. It should be held firmly against the person's skin, firmly
enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as
extra heart sounds or murmurs.
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should: - CORRECT ANSWER ANS: check the temperature of the room and offer
blankets to the patient if he or she feels cold.
The examination room should be warm. If the patient shivers, then the involuntary muscle
contractions can make it difficult to hear the underlying sounds. The end of the stethoscope
should be warmed between the examiner's hands, not with water. The nurse should never
listen through a gown. The diaphragm of the stethoscope should be used to auscultate for
bowel sounds.
The nurse will use which technique of assessment to determine the presence of crepitus,
swelling, and pulsations? - CORRECT ANSWER ANS: Palpation
Palpation applies the sense of touch to assess these factors: texture, temperature, moisture,
organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity,
crepitation, presence of lumps or masses, and presence of tenderness or pain.
The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope? The otoscope: - CORRECT ANSWER ANS: directs light into
the ear canal and onto the tympanic membrane.
The otoscope directs light into the ear canal and onto the tympanic membrane that divides the
external and middle ear. A short, broad speculum is used to visualize the nares.
UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
When performing a physical assessment, the technique the nurse will always use first is: -
CORRECT ANSWER ANS: inspection.
The skills requisite for the physical examination are inspection, palpation, percussion, and
auscultation. The skills are performed one at a time and in this order (with the exception of
the abdominal assessment, where auscultation takes place before palpation and percussion).
The assessment of each body system begins with inspection. A focused inspection takes time
and yields a surprising amount of information.
The nurse is preparing to perform a physical assessment. Which statement is true about the
inspection phase of the physical assessment? - CORRECT ANSWER ANS: Inspection
takes time and reveals a surprising amount of information.
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."
The nurse is assessing a patient's skin during an office visit. What is the best technique to use
to best assess the patient's skin temperature? Use the: - CORRECT ANSWER ANS:
dorsal surface of the hand because the skin is thinner than on the palms.
The dorsa (backs) of hands and fingers are best for determining temperature because the skin
there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other
responses are not useful for palpation.
Which of these techniques uses the sense of touch to assess texture, temperature, moisture,
and swelling when the nurse is assessing a patient? - CORRECT ANSWER ANS:
Palpation
,Palpation uses the sense of touch to assess the patient for these factors. Inspection involves
vision; percussion assesses through the use of palpable vibrations and audible sounds; and
auscultation uses the sense of hearing.
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse
proceed? - CORRECT ANSWER ANS: Start with light palpation to detect surface
characteristics and to accustom the patient to being touched.
Light palpation is performed initially to detect any surface characteristics and to accustom the
person to being touched. Tender areas should be palpated last, not first.
The nurse would use bimanual palpation technique in which situation? - CORRECT
ANSWER ANS: Palpating the kidneys and uterus
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.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is
to assess the underlying tissue: - CORRECT ANSWER ANS: density.
Percussion yields a sound that depicts the location, size, and density of the underlying organ.
Turgor and texture are assessed with palpation.
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: -
CORRECT ANSWER ANS: percusses once over each area.
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.
,When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
- CORRECT ANSWER ANS: consider this a normal finding.
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound.
The other responses are not correct.
The nurse is unable to identify any changes in sound when percussing over the abdomen of
an obese patient. What should the nurse do next? - CORRECT ANSWER ANS:
Increase the amount of strength used when attempting to percuss over the abdomen.
The thickness of the person's body wall will be a factor. The nurse will need a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the blow
determines the loudness of the note. The other actions are not correct.
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? - CORRECT ANSWER ANS:
Consider this a normal finding for a child this age and proceed with the examination.
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.
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? -
CORRECT ANSWER ANS: Percuss the thorax bilaterally, noting any differences in
percussion tones.
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.
The nurse is teaching a class on basic assessment skills. Which of these statements is true
regarding the stethoscope and its use? - CORRECT ANSWER ANS: The stethoscope
does not magnify sound but does block out extraneous room noise.
, The stethoscope does not magnify sound but does block out extraneous room sounds. The
slope of the earpieces should point forward toward the examiner's nose. Longer tubing will
distort sound. The fit and quality of the stethoscope are important.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm: - CORRECT
ANSWER ANS: is used to listen for high-pitched sounds.
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath,
bowel, and normal heart sounds. It should be held firmly against the person's skin, firmly
enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as
extra heart sounds or murmurs.
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should: - CORRECT ANSWER ANS: check the temperature of the room and offer
blankets to the patient if he or she feels cold.
The examination room should be warm. If the patient shivers, then the involuntary muscle
contractions can make it difficult to hear the underlying sounds. The end of the stethoscope
should be warmed between the examiner's hands, not with water. The nurse should never
listen through a gown. The diaphragm of the stethoscope should be used to auscultate for
bowel sounds.
The nurse will use which technique of assessment to determine the presence of crepitus,
swelling, and pulsations? - CORRECT ANSWER ANS: Palpation
Palpation applies the sense of touch to assess these factors: texture, temperature, moisture,
organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity,
crepitation, presence of lumps or masses, and presence of tenderness or pain.
The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope? The otoscope: - CORRECT ANSWER ANS: directs light into
the ear canal and onto the tympanic membrane.
The otoscope directs light into the ear canal and onto the tympanic membrane that divides the
external and middle ear. A short, broad speculum is used to visualize the nares.
