Chapter 21: Physical Assessment
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 21, Physical Assessment
Objective: 3. Differentiate between a comprehensive health assessment, a focused assessment, and an initial
head-to-toe shift assessment.
Page: 389
Heading: What Is Physical Assessment? > Three Levels of Physical Assessment
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Physiologic Concepts | Perfusion
Difficulty: Difficult
Feedback
1 This is incorrect. To decrease the client’s frustration, it is best to explain the reason that
the client is being awakened for a focused assessment. The nurse’s comment does not
answer the client’s question.
2 This is incorrect. Although the assessment may or may not have been ordered by the
physician, it is better for the nurse to explain why the assessment is being performed.
3 This is incorrect. A head-to-toe assessment is the first assessment of the shift and gives
the nurse a quick overall picture of the client.
4 This is correct. A focusedNaUsRseSssImNenGt TinBvo.lvCeOs tMhe assessment of
a system. In this case,
the cardiovascular system is being assessed to evaluate the client’s response to new
medication. This comment specifically answers the client’s question.
PTS: 1 CON: Physiologic Concepts | Perfusion
2. ANS: 2
Chapter: Chapter 21, Physical Assessment
Objective: 3. Differentiate between a comprehensive health assessment, a focused assessment, and an initial
head-to-toe shift assessment.
Page: 389, 390
Heading: What Is Physical Assessment? > Purpose of Physical Assessment
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Concepts | Patient-Centered Care
Difficulty: Difficult
Feedback
1 This is incorrect. A comprehensive health assessment is done on each client on
admission but would not prompt the nurse to maintain or change the current plan of
care.
2 This is correct. The nurse should evaluate the effectiveness of nursing interventions
initiated for the client to determine whether it is necessary to make changes in a client’s
plan of care.
3 This is incorrect. It may be necessary for the nurse to change the facility’s general plans
for the delivery of care many times during the shift because of changes in clients, not
WWW.
, the amount of time that the nurse has to provide care.
4 This is incorrect. Learning that the client may be discharged will require changes in the
plan of care, possibly geared more toward client education; however, these changes
occur after a discharge becomes a reality.
PTS: 1 CON: Nursing Concepts | Patient-Centered Care
3. ANS: 1
Chapter: Chapter 21, Physical Assessment
Objective: 5. Summarize the six techniques used for physical assessment including their correct performance.
Page: 392
Heading: What Is Physical Assessment? > Six Assessment Techniques
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Nursing Concepts | Patient-Centered Care
Difficulty: Easy
Feedback
1 This is correct. Palpation is the application of manual pressure to detect abnormalities.
2 This is incorrect. Auscultation is listening with a stethoscope to detect certain sounds.
3 This is incorrect. Observation is the use of the eyes to visually examine the client.
4 This is incorrect. Olfaction involves smelling.
PTS: 1 CON: Nursing Concepts | Patient-Centered Care
4. ANS: 3
Chapter: Chapter 21, PhysicalNAUssResSsmIeNnGt TB.COM
Objective: 7. Explain the significance of abnormal assessment findings.
Page: 396
Heading: Assessment Components Related to Each Body System
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nursing Concepts | Patient-Centered Care
Difficulty: Moderate
Feedback
1 This is incorrect. Abnormal findings should be rechecked within 4 hours or less, but 15
minutes is too soon unless the blood pressure is critically elevated.
2 This is incorrect. Abnormal findings should be rechecked within 4 hours or less.
3 This is correct. Because the blood pressure has become moderately elevated since 8:00
a.m., it should be rechecked within 1 to 2 hours, even if this is a typical elevation in
blood pressure for this client.
4 This is incorrect. Because the blood pressure is now hypertensive, both systolic and
diastolic pressures will need to be rechecked.
PTS: 1 CON: Nursing Concepts | Patient-Centered Care
5. ANS: 2
Chapter: Chapter 21, Physical Assessment
Objective: 1. Define various terms associated with physical assessment.
Page: 390
Heading: What Is Physical Assessment? > Six Assessment Techniques
WWW.
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 21, Physical Assessment
Objective: 3. Differentiate between a comprehensive health assessment, a focused assessment, and an initial
head-to-toe shift assessment.
Page: 389
Heading: What Is Physical Assessment? > Three Levels of Physical Assessment
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Physiologic Concepts | Perfusion
Difficulty: Difficult
Feedback
1 This is incorrect. To decrease the client’s frustration, it is best to explain the reason that
the client is being awakened for a focused assessment. The nurse’s comment does not
answer the client’s question.
2 This is incorrect. Although the assessment may or may not have been ordered by the
physician, it is better for the nurse to explain why the assessment is being performed.
3 This is incorrect. A head-to-toe assessment is the first assessment of the shift and gives
the nurse a quick overall picture of the client.
4 This is correct. A focusedNaUsRseSssImNenGt TinBvo.lvCeOs tMhe assessment of
a system. In this case,
the cardiovascular system is being assessed to evaluate the client’s response to new
medication. This comment specifically answers the client’s question.
PTS: 1 CON: Physiologic Concepts | Perfusion
2. ANS: 2
Chapter: Chapter 21, Physical Assessment
Objective: 3. Differentiate between a comprehensive health assessment, a focused assessment, and an initial
head-to-toe shift assessment.
Page: 389, 390
Heading: What Is Physical Assessment? > Purpose of Physical Assessment
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Concepts | Patient-Centered Care
Difficulty: Difficult
Feedback
1 This is incorrect. A comprehensive health assessment is done on each client on
admission but would not prompt the nurse to maintain or change the current plan of
care.
2 This is correct. The nurse should evaluate the effectiveness of nursing interventions
initiated for the client to determine whether it is necessary to make changes in a client’s
plan of care.
3 This is incorrect. It may be necessary for the nurse to change the facility’s general plans
for the delivery of care many times during the shift because of changes in clients, not
WWW.
, the amount of time that the nurse has to provide care.
4 This is incorrect. Learning that the client may be discharged will require changes in the
plan of care, possibly geared more toward client education; however, these changes
occur after a discharge becomes a reality.
PTS: 1 CON: Nursing Concepts | Patient-Centered Care
3. ANS: 1
Chapter: Chapter 21, Physical Assessment
Objective: 5. Summarize the six techniques used for physical assessment including their correct performance.
Page: 392
Heading: What Is Physical Assessment? > Six Assessment Techniques
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Nursing Concepts | Patient-Centered Care
Difficulty: Easy
Feedback
1 This is correct. Palpation is the application of manual pressure to detect abnormalities.
2 This is incorrect. Auscultation is listening with a stethoscope to detect certain sounds.
3 This is incorrect. Observation is the use of the eyes to visually examine the client.
4 This is incorrect. Olfaction involves smelling.
PTS: 1 CON: Nursing Concepts | Patient-Centered Care
4. ANS: 3
Chapter: Chapter 21, PhysicalNAUssResSsmIeNnGt TB.COM
Objective: 7. Explain the significance of abnormal assessment findings.
Page: 396
Heading: Assessment Components Related to Each Body System
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nursing Concepts | Patient-Centered Care
Difficulty: Moderate
Feedback
1 This is incorrect. Abnormal findings should be rechecked within 4 hours or less, but 15
minutes is too soon unless the blood pressure is critically elevated.
2 This is incorrect. Abnormal findings should be rechecked within 4 hours or less.
3 This is correct. Because the blood pressure has become moderately elevated since 8:00
a.m., it should be rechecked within 1 to 2 hours, even if this is a typical elevation in
blood pressure for this client.
4 This is incorrect. Because the blood pressure is now hypertensive, both systolic and
diastolic pressures will need to be rechecked.
PTS: 1 CON: Nursing Concepts | Patient-Centered Care
5. ANS: 2
Chapter: Chapter 21, Physical Assessment
Objective: 1. Define various terms associated with physical assessment.
Page: 390
Heading: What Is Physical Assessment? > Six Assessment Techniques
WWW.
