The nurse will use which technique of assessment to determine the
presence of crepitus, swelling, and pulsations?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
RAT: Palpation applies the sense of touch to assess 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 the 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:
a. Is often used to direct light onto the sinuses.
b. Uses a short, broad speculum to help visualize the ear.
c. Is used to examine the structures of the internal ear.
, d. Directs light into the ear canal and onto the tympanic membrane.
RAT: 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.
An examiner is using an ophthalmoscope to examine a patient‘s eyes.
The patient has astigmatism and is nearsighted. The use of which of
these techniques would indicate that the examination is being correctly
performed?
a. Using the large full circle of light when assessing pupils that are not
dilated
b. Rotating the lens selector dial to the black numbers to compensate for
astigmatism
c. Using the grid on the lens aperture dial to visualize the external structures
of the eye
d. Rotating the lens selector dial to bring the object into focus
RAT: The ophthalmoscope is used to examine the internal eye
structures. It can compensate for nearsightedness or farsightedness, but
it will not correct for astigmatism. The grid is used to assess size and
location of lesions on the fundus. The large full spot of light is used to
assess dilated pupils. Rotating the lens selector dial brings the object
into focus.
A man is at the clinic for a physical examination. He states that he
is ―very anxious‖ about the physical examination. What steps can
the nurse take to make him more comfortable?
a. Appear unhurried and confident when examining him.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his
, undergarments.
d. Defer measuring vital signs until the end of the examination, which
allows him time to become comfortable.
RAT: Anxiety can be reduced by an examiner who is confident, self-
assured, considerate, and unhurried. Familiar and relatively
nonthreatening actions, such as measuring the person‘s vital signs, will
gradually accustom the person to the examination.
When performing a physical examination, safety must be considered
to protect the examiner and the patient against the spread of infection.
Which of these statements describes the most appropriate action the
nurse should take when performing a physical examination?
a. Washing one‘s hands after removing gloves is not necessary, as
long as the gloves are still intact.
b. Hands are washed before and after every physical patient encounter.
c. Hands are washed before the examination of each body
system to prevent the spread of bacteria from one part of the
body to another.
d. Gloves are worn throughout the entire examination to demonstrate to the
patient
, concern regarding the spread of infectious diseases.
RAT: The nurse should wash his or her hands before and after every
physical patient encounter; after contact with blood, body fluids,
secretions, and excretions; after contact with any equipment
contaminated with body fluids; and after removing gloves. Hands
should be washed after gloves have been removed, even if the gloves
appear to be intact. Gloves should be worn when potential contact with
any body fluids is present.
The nurse is examining a patient‘s lower leg and notices a draining
ulceration. Which of these actions is most appropriate in this situation?
a. Washing hands, and contacting the physician
b. Continuing to examine the ulceration, and then washing hands
c. Washing hands, putting on gloves, and continuing with the
examination of the ulceration
d. Washing hands, proceeding with rest of the physical
examination, and then continuing with the examination of
the leg ulceration
RAT: The examiner should wear gloves when the potential contact
with any body fluids is present. In this situation, the nurse should wash
his or her hands, put on gloves, and continue examining the
ulceration.
During the examination, offering some brief teaching about the
patient‘s body or the examiner‘s findings is often appropriate. Which
one of these statements by the nurse is most appropriate?
a. ―Your atrial dysrhythmias are under control.‖
b. ―You have pitting edema and mild varicosities.‖
presence of crepitus, swelling, and pulsations?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
RAT: Palpation applies the sense of touch to assess 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 the 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:
a. Is often used to direct light onto the sinuses.
b. Uses a short, broad speculum to help visualize the ear.
c. Is used to examine the structures of the internal ear.
, d. Directs light into the ear canal and onto the tympanic membrane.
RAT: 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.
An examiner is using an ophthalmoscope to examine a patient‘s eyes.
The patient has astigmatism and is nearsighted. The use of which of
these techniques would indicate that the examination is being correctly
performed?
a. Using the large full circle of light when assessing pupils that are not
dilated
b. Rotating the lens selector dial to the black numbers to compensate for
astigmatism
c. Using the grid on the lens aperture dial to visualize the external structures
of the eye
d. Rotating the lens selector dial to bring the object into focus
RAT: The ophthalmoscope is used to examine the internal eye
structures. It can compensate for nearsightedness or farsightedness, but
it will not correct for astigmatism. The grid is used to assess size and
location of lesions on the fundus. The large full spot of light is used to
assess dilated pupils. Rotating the lens selector dial brings the object
into focus.
A man is at the clinic for a physical examination. He states that he
is ―very anxious‖ about the physical examination. What steps can
the nurse take to make him more comfortable?
a. Appear unhurried and confident when examining him.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his
, undergarments.
d. Defer measuring vital signs until the end of the examination, which
allows him time to become comfortable.
RAT: Anxiety can be reduced by an examiner who is confident, self-
assured, considerate, and unhurried. Familiar and relatively
nonthreatening actions, such as measuring the person‘s vital signs, will
gradually accustom the person to the examination.
When performing a physical examination, safety must be considered
to protect the examiner and the patient against the spread of infection.
Which of these statements describes the most appropriate action the
nurse should take when performing a physical examination?
a. Washing one‘s hands after removing gloves is not necessary, as
long as the gloves are still intact.
b. Hands are washed before and after every physical patient encounter.
c. Hands are washed before the examination of each body
system to prevent the spread of bacteria from one part of the
body to another.
d. Gloves are worn throughout the entire examination to demonstrate to the
patient
, concern regarding the spread of infectious diseases.
RAT: The nurse should wash his or her hands before and after every
physical patient encounter; after contact with blood, body fluids,
secretions, and excretions; after contact with any equipment
contaminated with body fluids; and after removing gloves. Hands
should be washed after gloves have been removed, even if the gloves
appear to be intact. Gloves should be worn when potential contact with
any body fluids is present.
The nurse is examining a patient‘s lower leg and notices a draining
ulceration. Which of these actions is most appropriate in this situation?
a. Washing hands, and contacting the physician
b. Continuing to examine the ulceration, and then washing hands
c. Washing hands, putting on gloves, and continuing with the
examination of the ulceration
d. Washing hands, proceeding with rest of the physical
examination, and then continuing with the examination of
the leg ulceration
RAT: The examiner should wear gloves when the potential contact
with any body fluids is present. In this situation, the nurse should wash
his or her hands, put on gloves, and continue examining the
ulceration.
During the examination, offering some brief teaching about the
patient‘s body or the examiner‘s findings is often appropriate. Which
one of these statements by the nurse is most appropriate?
a. ―Your atrial dysrhythmias are under control.‖
b. ―You have pitting edema and mild varicosities.‖
