Answer Key
Question 1: Cranial nerve function is important for normal sensory
(see full functioning. Which cranial nerve is important for the
question)
sense of smell?
You selected: Cranial nerve II
Incorrect
Correct response: Cranial nerve I
Explanation: Cranial nerve I is important for a person's sense of smell. Cranial
nerves II, III, and IV are important for
vision.
Question 2: A 57-year-old male client is admitted to the medical unit
(see full with a 3- day history of sharp, nonradiating epigastric pain
question)
and vomiting. He denies seeing blood in his stool. When
assessing this client's abdomen, what assessment
technique would the nurse perform last?
You selected: Percussion
Incorrect
Correct response: Palpation
Explanation: The sequence of techniques used to assess the
abdomen is inspection, auscultation, percussion, and
palpation. Percussion and palpation are done after
auscultation because they stimulate bowel sounds.
(less)
Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015,
Chapter 25: Health Assessment, p. 659.
Question 3: Palpation is the use of hands and fingers to gather
(see full information through touch. Different parts of the hand are
question)
more suitable for different tactile sensations. Which part
of the hand is best for sensing temperature?
You selected: The dorsum
This study source was downloaded by 100000829878664 from CourseHero.com on 09-23-2023 13:22:31 GMT -05:00
https://www.coursehero.com/file/14591803/Answer-Ke2-25/
, Correct
Explanation: The skin over the dorsum of the hand is sensitive to
temperature because it is thin and its nerve density is
great. The palm of the hand is sensitive to vibration and
is useful in locating a vibration associated with a heart
murmur. The fingertips are concentrated with nerve
endings and can sense fine difference in texture and
consistency. The knuckles are not used in palpation.
(less)
Question 4: The nurse should use the bell of the stethoscope during
(see full
question) auscultation of:
You selected: a client's apical heart rate.
Incorrect
Correct response: a client's heart murmur.
Explanation: The bell of the stethoscope is used to listen to low-pitched
sounds,
such as heart murmurs. The diaphragm of the
stethoscope is used to listen to high-pitched sounds such
as normal heart sounds, breath sounds, and bowel
sounds. (less)
Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed.
Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins; 2015, Chapter 25: Health Assessment, pp. 632,
654.
Question 5: What respiratory sound indicates an upper airway obstruction?
(see full
question)
You selected: Dyspnea
Incorrect
Correct response: Stridor
Explanation: Stridor is a harsh inspiratory sound that can sound like crowing.
It
may indicate an upper airway
obstruction.
This study source was downloaded by 100000829878664 from CourseHero.com on 09-23-2023 13:22:31 GMT -05:00
https://www.coursehero.com/file/14591803/Answer-Ke2-25/
Question 1: Cranial nerve function is important for normal sensory
(see full functioning. Which cranial nerve is important for the
question)
sense of smell?
You selected: Cranial nerve II
Incorrect
Correct response: Cranial nerve I
Explanation: Cranial nerve I is important for a person's sense of smell. Cranial
nerves II, III, and IV are important for
vision.
Question 2: A 57-year-old male client is admitted to the medical unit
(see full with a 3- day history of sharp, nonradiating epigastric pain
question)
and vomiting. He denies seeing blood in his stool. When
assessing this client's abdomen, what assessment
technique would the nurse perform last?
You selected: Percussion
Incorrect
Correct response: Palpation
Explanation: The sequence of techniques used to assess the
abdomen is inspection, auscultation, percussion, and
palpation. Percussion and palpation are done after
auscultation because they stimulate bowel sounds.
(less)
Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015,
Chapter 25: Health Assessment, p. 659.
Question 3: Palpation is the use of hands and fingers to gather
(see full information through touch. Different parts of the hand are
question)
more suitable for different tactile sensations. Which part
of the hand is best for sensing temperature?
You selected: The dorsum
This study source was downloaded by 100000829878664 from CourseHero.com on 09-23-2023 13:22:31 GMT -05:00
https://www.coursehero.com/file/14591803/Answer-Ke2-25/
, Correct
Explanation: The skin over the dorsum of the hand is sensitive to
temperature because it is thin and its nerve density is
great. The palm of the hand is sensitive to vibration and
is useful in locating a vibration associated with a heart
murmur. The fingertips are concentrated with nerve
endings and can sense fine difference in texture and
consistency. The knuckles are not used in palpation.
(less)
Question 4: The nurse should use the bell of the stethoscope during
(see full
question) auscultation of:
You selected: a client's apical heart rate.
Incorrect
Correct response: a client's heart murmur.
Explanation: The bell of the stethoscope is used to listen to low-pitched
sounds,
such as heart murmurs. The diaphragm of the
stethoscope is used to listen to high-pitched sounds such
as normal heart sounds, breath sounds, and bowel
sounds. (less)
Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed.
Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins; 2015, Chapter 25: Health Assessment, pp. 632,
654.
Question 5: What respiratory sound indicates an upper airway obstruction?
(see full
question)
You selected: Dyspnea
Incorrect
Correct response: Stridor
Explanation: Stridor is a harsh inspiratory sound that can sound like crowing.
It
may indicate an upper airway
obstruction.
This study source was downloaded by 100000829878664 from CourseHero.com on 09-23-2023 13:22:31 GMT -05:00
https://www.coursehero.com/file/14591803/Answer-Ke2-25/
