NUR 2092 / NUR2092 Health Assessment Exam 2 Questions Bank Detailed Answers (100% Correct) with Rationales Rated A+!!!

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, organlocation 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 thatdivides 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 thatthe 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 oflight is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.  The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope. RAT: Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal hearttones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.  The nurse is preparing to perform a physical assessment. The correct action by the nurseis reflected by which statement? The nurse: a. Performs the examination from the left side of the bed. b. Examines tender or painful areas first to help relieve the patient’s anxiety. c. Follows the same examination sequence, regardless of the patient’s age orcondition. d. Organizes the assessment to ensure that the patient does not change positionstoo often. RAT: The steps of the assessment should be organized to ensure that the patient does notchange positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last.  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 timeto become comfortable. RAT: Anxiety can be reduced by an examiner who is confident, selfassured, 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 preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infant’s vital signs. RAT: The parent should always be present to increase the child’s feeling of security and to understand normal growth and development. The timing of the examination should be1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants donot object to being nude; clothing should be removed, but a diaper should be left on a boy.  A 6-month-old infant has been brought to the well-child clinic for a check-up. She iscurrently sleeping. What should the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant’s hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of theexamination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the mostaccurate assessment of body systems. RAT: When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat areinvasive procedures that should be performed at the end of the examination.  A 2-year-old child has been brought to the clinic for a well-child checkup. The best wayfor the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the child’s clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during theexamination. d. Initially focus the interactions on the child, essentially ignoring the parent until thechild’s trust has been obtained. RAT: The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-oldchild does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.  The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?”Which critique of the nurse’s technique is most accurate? a. Asking questions enhances the child’s autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like tohave choices d. Children at this age like to say, “No.” The examiner should not offer a choicewhen no choice is available RAT: Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then thenurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?”  With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent RAT: When assessing preschool children, using games or allowing them to play with theequipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups.  The nurse is preparing to examine a 4-year-old child. Which action is appropriate for thisage group? a. Explain the procedures in detail to alleviate the child’s anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this ageare usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine thethorax and abdomen. RAT: With preschool children, short, simple explanations should be used. Children at thisage are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler.  When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to beinterested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination toanswer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because ateen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the widevariation among teenagers on the rate of growth and development. RAT: During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body imageand often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.  When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes aspossible. RAT: When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially importantwith the older person because other senses may be diminished.  The most important step that the nurse can take to prevent the transmission ofmicroorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients. RAT: The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient.Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each timehand hygiene is performed.  Which of these statements is true regarding the use of Standard Precautions in the healthcare setting? a. Standard Precautions apply to all body fluids, including sweat. b. Use alcohol-based hand rub if hands are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of theirrisk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containingvisible blood, or expected contact with mucous membranes is present. RAT: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat— regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood orbody fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.  The nurse is preparing to assess a hospitalized patient who is experiencing significantshortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory,and abdominal assessment. b. A thorough history and physical assessment information should be obtained fromthe patient’s family member. c. A complete history and physical assessment should be immediately performed toobtain baseline information. d. Body areas appropriate to the problem should be examined and thenthe assessment completed after the problem has resolved. RAT: Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessaryin this situation. An assessment may be completed later after the distress is resolved.  When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen RAT: The least-distressing steps are performed first, saving the invasive steps of theexamination of the eye, ear, nose, and throat until last.  While auscultating heart sounds, the nurse hears a murmur. Which of these instrumentsshould be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse’s palm of the hand RAT: The bell of the stethoscope is best for soft, low-pitched sounds such as extra heartsounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.  When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. RAT: The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes placebefore palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.  The nurse is preparing to perform a physical assessment. Which statement is true aboutthe physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before proceeding withpalpation. RAT: A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doingsomething. A focused assessment is significantly more than a “quick glance.”  The nurse is assessing a patient’s skin during an office visit. What part of the hand andtechnique should be used to best assess the patient’s skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperaturesensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variationsbecause of its increased nerve supply in this area. RAT: The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are bestfor fine, tactile discrimination. The other responses are not useful for palpation.  Which of these techniques uses the sense of touch to assess texture, temperature,moisture, and swelling whenThe 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, organlocation 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 thatdivides 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 thatthe 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 oflight is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.  The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope. RAT: Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal hearttones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.  The nurse is preparing to perform a physical assessment. The correct action by the nurseis reflected by which statement? The nurse: a. Performs the examination from the left side of the bed. b. Examines tender or painful areas first to help relieve the patient’s anxiety. c. Follows the same examination sequence, regardless of the patient’s age orcondition. d. Organizes the assessment to ensure that the patient does not change positionstoo often. RAT: The steps of the assessment should be organized to ensure that the patient does notchange positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last.  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 timeto become comfortable. RAT: Anxiety can be reduced by an examiner who is confident, selfassured, 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 preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infant’s vital signs. RAT: The parent should always be present to increase the child’s feeling of security and to understand normal growth and development. The timing of the examination should be1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants donot object to being nude; clothing should be removed, but a diaper should be left on a boy.  A 6-month-old infant has been brought to the well-child clinic for a check-up. She iscurrently sleeping. What should the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant’s hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of theexamination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the mostaccurate assessment of body systems. RAT: When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat areinvasive procedures that should be performed at the end of the examination.  A 2-year-old child has been brought to the clinic for a well-child checkup. The best wayfor the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the child’s clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during theexamination. d. Initially focus the interactions on the child, essentially ignoring the parent until thechild’s trust has been obtained. RAT: The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-oldchild does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.  The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?”Which critique of the nurse’s technique is most accurate? a. Asking questions enhances the child’s autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like tohave choices d. Children at this age like to say, “No.” The examiner should not offer a choicewhen no choice is available RAT: Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then thenurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?”  With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent RAT: When assessing preschool children, using games or allowing them to play with theequipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups.  The nurse is preparing to examine a 4-year-old child. Which action is appropriate for thisage group? a. Explain the procedures in detail to alleviate the child’s anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this ageare usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine thethorax and abdomen. RAT: With preschool children, short, simple explanations should be used. Children at thisage are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler.  When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to beinterested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination toanswer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because ateen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the widevariation among teenagers on the rate of growth and development. RAT: During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body imageand often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.  When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes aspossible. RAT: When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially importantwith the older person because other senses may be diminished.  The most important step that the nurse can take to prevent the transmission ofmicroorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients. RAT: The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient.Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each timehand hygiene is performed.  Which of these statements is true regarding the use of Standard Precautions in the healthcare setting? a. Standard Precautions apply to all body fluids, including sweat. b. Use alcohol-based hand rub if hands are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of theirrisk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containingvisible blood, or expected contact with mucous membranes is present. RAT: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat— regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood orbody fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.  The nurse is preparing to assess a hospitalized patient who is experiencing significantshortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory,and abdominal assessment. b. A thorough history and physical assessment information should be obtained fromthe patient’s family member. c. A complete history and physical assessment should be immediately performed toobtain baseline information. d. Body areas appropriate to the problem should be examined and thenthe assessment completed after the problem has resolved. RAT: Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessaryin this situation. An assessment may be completed later after the distress is resolved.  When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen RAT: The least-distressing steps are performed first, saving the invasive steps of theexamination of the eye, ear, nose, and throat until last.  While auscultating heart sounds, the nurse hears a murmur. Which of these instrumentsshould be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse’s palm of the hand RAT: The bell of the stethoscope is best for soft, low-pitched sounds such as extra heartsounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.  When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. RAT: The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes placebefore palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.  The nurse is preparing to perform a physical assessment. Which statement is true aboutthe physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before proceeding withpalpation. RAT: A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doingsomething. A focused assessment is significantly more than a “quick glance.”  The nurse is assessing a patient’s skin during an office visit. What part of the hand andtechnique should be used to best assess the patient’s skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperaturesensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variationsbecause of its increased nerve supply in this area. RAT: The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are bestfor fine, tactile discrimination. The other responses are not useful for palpation.  Which of these techniques uses the sense of touch to assess texture, temperature,moisture, and swelling whenThe 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, organlocation 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 thatdivides 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 thatthe 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 oflight is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.  The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope. RAT: Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal hearttones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.  The nurse is preparing to perform a physical assessment. The correct action by the nurseis reflected by which statement? The nurse: a. Performs the examination from the left side of the bed. b. Examines tender or painful areas first to help relieve the patient’s anxiety. c. Follows the same examination sequence, regardless of the patient’s age orcondition. d. Organizes the assessment to ensure that the patient does not change positionstoo often. RAT: The steps of the assessment should be organized to ensure that the patient does notchange positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last.  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 timeto become comfortable. RAT: Anxiety can be reduced by an examiner who is confident, selfassured, 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 preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infant’s vital signs. RAT: The parent should always be present to increase the child’s feeling of security and to understand normal growth and development. The timing of the examination should be1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants donot object to being nude; clothing should be removed, but a diaper should be left on a boy.  A 6-month-old infant has been brought to the well-child clinic for a check-up. She iscurrently sleeping. What should the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant’s hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of theexamination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the mostaccurate assessment of body systems. RAT: When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat areinvasive procedures that should be performed at the end of the examination.  A 2-year-old child has been brought to the clinic for a well-child checkup. The best wayfor the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the child’s clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during theexamination. d. Initially focus the interactions on the child, essentially ignoring the parent until thechild’s trust has been obtained. RAT: The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-oldchild does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.  The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?”Which critique of the nurse’s technique is most accurate? a. Asking questions enhances the child’s autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like tohave choices d. Children at this age like to say, “No.” The examiner should not offer a choicewhen no choice is available RAT: Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then thenurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?”  With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent RAT: When assessing preschool children, using games or allowing them to play with theequipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups.  The nurse is preparing to examine a 4-year-old child. Which action is appropriate for thisage group? a. Explain the procedures in detail to alleviate the child’s anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this ageare usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine thethorax and abdomen. RAT: With preschool children, short, simple explanations should be used. Children at thisage are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler.  When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to beinterested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination toanswer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because ateen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the widevariation among teenagers on the rate of growth and development. RAT: During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body imageand often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.  When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes aspossible. RAT: When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially importantwith the older person because other senses may be diminished.  The most important step that the nurse can take to prevent the transmission ofmicroorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients. RAT: The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient.Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each timehand hygiene is performed.  Which of these statements is true regarding the use of Standard Precautions in the healthcare setting? a. Standard Precautions apply to all body fluids, including sweat. b. Use alcohol-based hand rub if hands are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of theirrisk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containingvisible blood, or expected contact with mucous membranes is present. RAT: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat— regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood orbody fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.  The nurse is preparing to assess a hospitalized patient who is experiencing significantshortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory,and abdominal assessment. b. A thorough history and physical assessment information should be obtained fromthe patient’s family member. c. A complete history and physical assessment should be immediately performed toobtain baseline information. d. Body areas appropriate to the problem should be examined and thenthe assessment completed after the problem has resolved. RAT: Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessaryin this situation. An assessment may be completed later after the distress is resolved.  When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen RAT: The least-distressing steps are performed first, saving the invasive steps of theexamination of the eye, ear, nose, and throat until last.  While auscultating heart sounds, the nurse hears a murmur. Which of these instrumentsshould be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse’s palm of the hand RAT: The bell of the stethoscope is best for soft, low-pitched sounds such as extra heartsounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.  When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. RAT: The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes placebefore palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.  The nurse is preparing to perform a physical assessment. Which statement is true aboutthe physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before proceeding withpalpation. RAT: A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doingsomething. A focused assessment is significantly more than a “quick glance.”  The nurse is assessing a patient’s skin during an office visit. What part of the hand andtechnique should be used to best assess the patient’s skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperaturesensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variationsbecause of its increased nerve supply in this area. RAT: The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are bestfor fine, tactile discrimination. The other responses are not useful for palpation.  Which of these techniques uses the sense of touch to assess texture, temperature,moisture, and swelling when