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Chapter 31: Health Assessment and Physical
Examination
Chapter 31: Health Assessment and Physical Examination
Potter et al.: Fundamentals of Nursing, 9th 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 ᴀ밄gure out if your antihypertensive medication is working
eᴀ洅ectively.”
b. “Nursing assessment data are used only to provide information about the eᴀ洅ectiveness 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 eᴀ洅ectiveness of all aspects of a patient’s care, not just the
patient’s medical care. Assessment data help to evaluate the eᴀ洅ectiveness 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)REF:533-534
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,10/15/2016 Chapter 31: Health Assessment and Physical Examination | Nursing Test Banks
OBJ iscuss 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 identiᴀ밄es self, washes hands with soap, and states the purpose of the visit. The nurse
performs proper identiᴀ밄cation 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. 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)REF:541
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 weak, older-adult patient with
bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims’
c. Supine
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,10/15/2016 Chapter 31: Health Assessment and Physical Examination | Nursing Test Banks
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 diᴀ甇culty for any patient with respiratory diᴀ甇culties. Sims’
position is used for assessment of the rectum and the vagina.
DIF:Apply (application)REF:536
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)REF:560
OBJ: Demonstrate the techniques used with each physical assessment skill.
TOP: Implementation MSC: Health Promotion and Maintenance
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, 10/15/2016 Chapter 31: Health Assessment and Physical Examination | Nursing Test Banks
5. A head and neck physical examination is completed on a 50-year-old female patient. All physical ᴀ밄ndings are
normal except for ᴀ밄ne brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the
physical ᴀ밄ndings?
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)REF:549 | 565
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 the illness history and the presence of small, circumscribed skin lesions ᴀ밄lled with serous ᴀ밄uid. Which
type of skin lesion will the nurse report?
a. Vesicles
b. Wheals
c. Papules
d. Pustules
ANS: A
http://boostgrade.info/chapter31healthassessmentandphysicalexamination/ 4/31
Nursing Test Banks
One Account Get all Test Banks
Chapter 31: Health Assessment and Physical
Examination
Chapter 31: Health Assessment and Physical Examination
Potter et al.: Fundamentals of Nursing, 9th 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 ᴀ밄gure out if your antihypertensive medication is working
eᴀ洅ectively.”
b. “Nursing assessment data are used only to provide information about the eᴀ洅ectiveness 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 eᴀ洅ectiveness of all aspects of a patient’s care, not just the
patient’s medical care. Assessment data help to evaluate the eᴀ洅ectiveness 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)REF:533-534
http://boostgrade.info/chapter31healthassessmentandphysicalexamination/ 1/31
,10/15/2016 Chapter 31: Health Assessment and Physical Examination | Nursing Test Banks
OBJ iscuss 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 identiᴀ밄es self, washes hands with soap, and states the purpose of the visit. The nurse
performs proper identiᴀ밄cation 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. 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)REF:541
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 weak, older-adult patient with
bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims’
c. Supine
http://boostgrade.info/chapter31healthassessmentandphysicalexamination/ 2/31
,10/15/2016 Chapter 31: Health Assessment and Physical Examination | Nursing Test Banks
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 diᴀ甇culty for any patient with respiratory diᴀ甇culties. Sims’
position is used for assessment of the rectum and the vagina.
DIF:Apply (application)REF:536
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)REF:560
OBJ: Demonstrate the techniques used with each physical assessment skill.
TOP: Implementation MSC: Health Promotion and Maintenance
http://boostgrade.info/chapter31healthassessmentandphysicalexamination/ 3/31
, 10/15/2016 Chapter 31: Health Assessment and Physical Examination | Nursing Test Banks
5. A head and neck physical examination is completed on a 50-year-old female patient. All physical ᴀ밄ndings are
normal except for ᴀ밄ne brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the
physical ᴀ밄ndings?
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)REF:549 | 565
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 the illness history and the presence of small, circumscribed skin lesions ᴀ밄lled with serous ᴀ밄uid. Which
type of skin lesion will the nurse report?
a. Vesicles
b. Wheals
c. Papules
d. Pustules
ANS: A
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