Exam (elaborations) RNSG 1216 Skills Physical Assessment Module Quiz/RNSG 1216 Skills Physical Assessment Module Quiz. Latest 2021

Exam (elaborations) RNSG 1216 Skills Physical Assessment Module Quiz/RNSG 1216 Skills Physical Assessment Module Quiz. Latest 2021 Exam (elaborations) RNSG 1216 Skills Physical Assessment Module Quiz/RNSG 1216 Skills Physical Assessment Module Quiz. Latest 2021 Name: Date: Kirsten Mashimo 2018‐1‐22 Time: 22:47:49 Quiz completed in: Questions answered: Number correct: 6.21 mins 34 33 (97%) QUESTION 1: When performing a head‐to‐toe physical assessment, which of the following would the nurse least likely assess during the general survey? Your Response: Correct Response: Correct! Vision Explanation: The general survey includes assessment about the patient's overall appearance and behavior, including areas such as hygiene, grooming, level of alertness, vital signs, and height and weight. Assessment of the eyes would address vision.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 87  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Beginning the Physical Assessment  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐1: Performing a General Survey QUESTION 2: When assessing the temporal artery, the nurse would palpate the face at which area? Your Response: Correct Response: Correct! Between the top of the ear and the eye. Explanation: The temporal arteries are located on each side of the face, between the top of the ear and the eye. The nurse palpates the mastoid process just below the ear lobe. The sinuses are located on either side of the nose.   Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Head QUESTION 3: The nurse uses which of the following to assess the temperature of a patient's hands? Your Response: Correct Response: Correct! Back of the hand. Explanation: When assessing the temperature of a patient's hands, the nurse uses the back side of his or her hand. The pads of the fingers are used to assess the pulse. Capillary refill is assessed by pressing on the patient's nail beds. The ulnar surface of the hand is not used to assess temperature.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 96  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Arms, Hands, and Fingers QUESTION 4: The nurse asks the patient to say "ahh." Which finding would the nurse identify as normal"? Your Response: Correct Response: Correct! Rising of the uvula. Explanation: When a patient says "ahh," the uvula should rise. Gagging would indicate an intact gag reflex. The tongue should not move to the side or retract when the patient says "ahh."  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 103  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Mouth and Throat  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐4: Assessing the Head and Neck QUESTION 5: Which of the following would the nurse do first when assessing a patient's ears? Your Response: Correct Response: Correct! Inspect the external ear. Explanation: When assessing a patient's ears, the nurse would first inspect the external ear (the tragus, auricle, and lobule). Next, the nurse would palpate the auricle and then the mastoid process. If necessary, the nurse would perform an otoscopic exam.   Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 102  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Ears  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐4: Assessing the Head and Neck QUESTION 6: When assessing the patient's carotid arteries, the nurse palpates one carotid artery at a time to prevent which of the following? Your Response: Correct Response: Correct! Reduced cerebral blood flow. Explanation: The carotid arteries are palpated one at a time to prevent a reduction in cerebral blood flow. Bilateral palpation of the carotid arteries does not increase venous return to the heart, decrease neck range of motion, or interrupt nerve transmission.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 104  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Neck  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐4: Assessing the Head and Neck QUESTION 7: After assessing a patient's neck, which finding would the nurse identify as abnormal? Your Response: Correct Response: Correct! Palpable thyroid gland. Explanation: Normal findings associated with assessment of the neck include a midline trachea, non‐palpable pre‐ and post‐auricular nodes, no bruits in the carotid arteries, and a non‐palpable thyroid gland.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 104  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Neck  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐4: Assessing the Head and Neck  QUESTION 8: When percussing the lungs, the nurse would expect to note which of the following? Your Response: Correct Response: Correct! Resonance Explanation: Percussion of the lungs should reveal resonance. Dullness is typically heard over more solid tissue. Tympany is heard over air, and flatness is heard over very dense tissue.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Posterior and Lateral Thorax QUESTION 9: The nurse asks a patient to say "ninety‐nine" while assessing the posterior thorax. The nurse is assessing for which of the following? Your Response: Correct Response: c) Crepitus Tactile fremitus Explanation: Asking the patient to say "ninety‐nine" is used to assess for tactile fremitus. The nurse uses palpation to assess for crepitus, which would feel similar to a crackling sensation. The nurse assesses chest expansion with both hands at the level of T9 or T10, and then asks the patient to take a deep breath, noting the distance between the thumbs. Percussion is used to assess tone.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Posterior and Lateral Thorax QUESTION 10: When palpating the posterior thorax, the nurse would palpate in which manner? Your Response: Correct Response: Correct! Start on the left and then move to the right, following a zigzag pattern down the back. Explanation: To palpate the posterior thorax, the nurse starts on one side of the back at the shoulder area and then moves to the other side at the same level. The nurse moves down on that same side and then over to the other side, continuing this zigzag pattern all the way down the posterior thorax.   Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 109  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Posterior and Lateral Thorax  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐5: Assessing the Thorax, Lungs, and Breasts QUESTION 11: A nurse is assessing a patient's anterior thorax to determine the quality and pattern of the patient's respirations. Which of the following would the nurse least likely assess? Your Response: Correct Response: Correct! Retraction Explanation: The quality and pattern of respirations include the rate, depth, and rhythm. Although retractions, when present, are an important finding suggesting respiratory difficulty, they do not reflect the quality and pattern of the respirations.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Anterior Thorax QUESTION 12: When assessing a patient's heart, which of the following would the nurse do first? Your Response: Correct Response: Correct! Inspect for visible pulsations. Explanation: The first step in assessing the patient's heart is to inspect the chest for visible pulsations. Next, the nurse would palpate for pulsations and palpate the apical impulse. Lastly, the nurse would auscultate over the apex.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 115 QUESTION 13: The nurse asks a patient to smile, blow out his cheeks, raise his eyebrows, and close his eyes tightly. The nurse is assessing which cranial nerve? Your Response: Correct Response: Correct! VII Explanation: Smiling, raising eyebrows, closing eyes tightly, and blowing out cheeks indicate adequate functioning of cranial nerve VII. To test cranial nerve V, the nurse would ask the patient to close his or her eyes and then identify where the nurse has touched his or her face. Checking the gag reflex tests cranial nerves IX and X.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 128  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Head QUESTION 14: The nurse assesses a patient's chest expansion and observes the movement of the thumbs. The nurse determines that there is a potential problem when thumb movement is which of the following? Your Response: Correct Response: Correct! 3 cm Explanation: When assessing chest expansion, the thumbs typically move apart 5 to 10 cm. Therefore, movement of only 3 cm would suggest a problem.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Posterior and Lateral Thorax QUESTION 15: The nurse auscultates the heart and listens for murmurs at which location? Your Response: Correct Response: Correct! Erb's point Explanation: Murmurs are auscultated at Erb's point. Auscultation at the mitral area or the apex reveals S1 heart sound. Auscultation at the pulmonic area reveals S2 heart sound.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 116  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Heart  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐6: Assessing the Cardiovascular System  QUESTION 16: The nurse asks the patient to turn his head to one side and touch his chin to his shoulder. The nurse is assessing for which of the following? Your Response: Correct! Correct Response: Range of motion Explanation: Asking the patient to move his head and neck evaluates range of motion. Swelling and symmetry are noted by inspecting and palpating the neck. Lymph nodes are evaluated by palpation.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 105  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Neck  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐4: Assessing the Head and Neck QUESTION 17: The nurse is preparing to assess a patient's abdomen. The nurse would place the patient in which position? Your Response: Correct Response: Correct! Supine Explanation: When examining the abdomen, the nurse would ensure that the patient is supine.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 118  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Abdomen  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐7: Assessing the Abdomen QUESTION 18: The nurse is palpating the posterior tibial pulse. At which location would the nurse position the fingers? Your Response: Correct Response: Correct! In the groove between the ankle and Achilles tendon. Explanation: The posterior tibial pulse is located in the groove between the ankle and Achilles tendon. The popliteal pulse is located behind the knee. The femoral pulse is located in the groin. The dorsalis pedis pulse is located at the top of the foot along the big toe.   Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 56  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Legs, Feet and Toes QUESTION 19: To assess capillary refill of the toes, which of the following would the nurse do? Your Response: Correct Response: Correct! Press firmly on the nail bed. Explanation: Capillary refill is assessed by pressing the nail bed firmly and then watching the color of the nail bed return. Asking the patient to point the toes upward or move the foot in a circle assesses range of motion. Palpating the skin of the feet assesses skin temperature and identifies any areas of tenderness, pain, swelling, or other irregularities.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 126  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Legs, Feet and Toes QUESTION 20: When assessing position sense, which of the following would be most important for the nurse to do? Your Response: Correct Response: Correct! Have the patient close his eyes. Explanation: When assessing the patient's position sense, it would be most important for the nurse to ensure that the patient's eyes are closed. The nurse would then test position sense by moving the patient's toes in different directions and asking the patient to indicate the direction the toe is being moved. However, this must be done with the patient's eyes closed; otherwise, the results would be inaccurate. The nurse would touch the patient's leg in various locations to assess sensation. With the heel‐shin test, the nurse would have the patient move the heel of one foot down the shin of the opposite leg.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Musculoskeletal and Neurological Systems  QUESTION 21: When assessing a patient's patellar reflex, which of the following would be most appropriate? Your Response: Correct Response: Correct! Having the patient sit upright with legs dangling freely. Explanation: The nurse would have the patient sit upright with legs dangling freely, leg muscles relaxed, and the feet off the ground.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Musculoskeletal and Neurological Systems QUESTION 22: The nurse is preparing to assess for the Romberg's test. The nurse would most likely do this when assessing which of the following? Your Response: Correct Response: Correct! Musculoskeletal and neurological systems Explanation: Romberg testing typically occurs during the assessment of the musculoskeletal and neurological systems. It is not a component of the abdominal assessment or assessment of the legs, feet, and toes or the arms, hands, and fingers.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 133  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Musculoskeletal and Neurological Systems  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill 3‐10: Assessing the Neurologic Musculoskeletal, and Peripheral Vascular Systems QUESTION 23: When performing a physical assessment, which of the following would the nurse do as the last step? Your Response: Correct Response: Correct! Document the assessment findings. Explanation: When the physical assessment is completed, the nurse's last step is to document the findings. The genitourinary and rectal exams are typically completed by the nurse practitioner or physician. Evaluation of the patient's legs, feet, and toes would occur before the assessment of the musculoskeletal and neurological systems.   Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Conclusion QUESTION 24: The nurse is assessing the patient's nose. For which of the following would the nurse palpate the external nose? Your Response: Correct! Correct Response: Tenderness Explanation: The nurse palpates the external nose for tenderness and inspects it for color, shape, and consistency.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 102  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Nose and Sinuses  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐4: Assessing the Head and Neck QUESTION 25: The nurse inspects a patient's abdomen. Which finding would alert the nurse to a possible problem? Your Response: Correct Response: Correct! Visible pulsations Explanation: Visible pulsations would be an abnormal finding. Pale pink skin color, flat and evenly rounded contour, and midline umbilicus are normal findings.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 118  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Abdomen  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐7: Assessing the Abdomen QUESTION 26: When percussing the abdomen over the liver, the nurse would expect to find which of the following? Your Response: Correct Response: Correct! Dullness Explanation: Percussion over the liver, a solid organ, would produce dullness. Percussion over the stomach, an air‐filled structure, would produce tympany. Flatness would be noted over very dense tissue, such as muscle or bone. Resonance would be noted over areas that are part solid and part air, such as the lungs.   Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Abdomen QUESTION 27: When assessing a patient's heart sounds, the nurse hears the "lub‐dub." The nurse identifies the "lub" as corresponding to which of the following? Your Response: Correct Response: Correct! S1 Explanation: The "lub" of the "lub‐dub" sound corresponds to the first or S1 heart sound. The "dub" corresponds to the second or S2 heart sound. S3 and S4 are abnormal heart sounds.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 113  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Heart  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐6: Assessing the Cardiovascular System QUESTION 28: Which of the following would the nurse use to locate the apical impulse of the heart? Your Response: Correct Response: Correct! Palmar surface of the hand. Explanation: To locate the apical impulse of the heart, the nurse uses the palmar surface of the hand placed in the apical or mitral area. Once found, the nurse then uses one or two fingertips to palpate the pulse. The ulnar surface of the hand may be used to palpate for fremitus. The pad of the thumb typically is not used for palpation.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 115 QUESTION 29: When preparing to assess a patient's mouth and throat, which of the following would be least appropriate to have on hand? Your Response: Correct Response: Correct! Stethoscope Explanation: To complete an assessment of a patient's mouth and throat, the nurse needs disposable gloves, a penlight, and a tongue depressor. There is no need for a stethoscope for this area of the exam.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, pp. 102‐103  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Mouth and Throat  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐4: Assessing the Head and Neck QUESTION 30: When assessing the head, the nurse would assess which of the following first? Your Response: Correct Response: Correct! Head shape Explanation: The nurse begins examining the head by inspecting the head for shape and size. This is followed by assessing the distribution, color, and consistency of the hair. Lastly, the nurse inspects the face and then tests cranial nerve VII.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 99  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Head  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐4: Assessing the Head and Neck QUESTION 31: A group of students is reviewing the techniques for assessing the abdomen. The students demonstrate understanding of the techniques when they identify which of the following as the proper sequence? Your Response: Correct Response: Correct! Inspection, auscultation, percussion, and palpation. Explanation: When assessing the abdomen, inspection is followed by auscultation to prevent altering the pattern of bowel sounds. Then the nurse would percuss and palpate.   Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 117  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Abdomen  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐7: Assessing the Abdomen QUESTION 32: The nurse is assessing airflow and the patency of the patient's nostrils. Which of the following would the nurse have the patient do? Your Response: Correct Response: Correct! Occlude one nostril while deeply inhaling through the other. Explanation: To properly assess airflow and patency of the nostrils, the nurse would have the patient use a finger to close off one nostril and then deeply inhale through the other. The nurse would have the patient do the same action on the other nostril. Breathing in and out of the mouth and nose, blowing the nose, or holding the breath would be inappropriate.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 102  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Nose and Sinuses  Lynn, Skill Checklists for Taylor’s Clinical Nursing Skills, 4th Edition, Skill Checklist 3‐4: Assessing the Head and Neck QUESTION 33: While auscultating a patient's bowel sounds, which of the following would the nurse identify as abnormal? Your Response: Correct Response: Correct! Rapid high‐pitched swooshing Explanation: Normal bowel sounds are typically heard as soft clicks or gurgles that occur at a rate of 5 to 30 per minute. Rapid high‐pitched swooshing would be considered abnormal.  Lynn, Taylor's Clinical Nursing Skills, 4th Edition, p. 119 QUESTION 34: The nurse is assessing a patient's popliteal pulse. Which action would be most appropriate? Your Response: Correct Response: Correct! Palpating with thumbs on top and the fingers deep in the back of a slightly flexed knee. Explanation: The popliteal pulse is located behind the knee. The nurse places the thumbs on top of the knee and the fingers deep in the back of the knee while the patient's knee is slightly flexed. The femoral pulse is located in the groin area, but the patient does not need to flex either leg when it is being assessed. The radial pulse is assessed by placing the fingers at the wrist along the thumb side. The brachial pulse is assessed by placing the fingers along the inner aspect of the arm at the elbow.  Taylor, Lillis, and Lynn, Taylor’s Video Guide to Clinical Nursing Skills, 3rd Edition, Physical Assessment: Assessing the Legs, Feet, and Toes 