Final-Comprehensive Physical
Assess. of an Adult (pretest)
Questions and Answers.
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the
following actions should the nurse plan to take first? - Answer DEVELOP PLAN OF CARE
- The first actions the nurse should take using nursing process is to assess the client and develop
a plan of care. The nursing process follows The steps of assessment, analysis, planning,
implementation and evaluation
A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following
instructions should the nurse include? - Answer "INSERT THE EARPIECE AT A DOWNWARD
ANGLE TOWARD YOUR NOSE"
- The nurse should insert the earpieces at a downward angle toward their nose because it helps
ensure that sounds are effectively transmitted to their eardrums.
A nurse is performing examination of the spine for an older adult client. The nurse should
identify that which of the following findings is common with age? - Answer KYPHOSIS
- Kyphosis - "hunchback" curvature of the spine is an abnormal angulation of the posterior curve
of the thoracic spine - usually resulting in osteoporosis. Most common in older adults and
increases with age.
A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over
the area with their fingers, then quickly releases it. The client reports increased pain on the
release of pressure. Which of the following findings should the nurse document? - Answer
REBOUND TENDERNESS
- The nurse should document that the client is experiencing rebound tenderness. Which is an
increase in pain when deep palpation over a tender area is released. Rebound tenderness in the
right lower quadrant at McBurney's point (one third the distance from the anterior iliac crest to
the umbilicus)is an indication of acute appendicitis.
A nurse is performing preparation to conduct a Romberg test on a client. The nurse should
explain to the client that the Romberg test is used to assess which of the following
characteristics? - Answer BALANCE
- Nurse should explain that the Romberg test is the most common test of balance
Assess. of an Adult (pretest)
Questions and Answers.
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the
following actions should the nurse plan to take first? - Answer DEVELOP PLAN OF CARE
- The first actions the nurse should take using nursing process is to assess the client and develop
a plan of care. The nursing process follows The steps of assessment, analysis, planning,
implementation and evaluation
A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following
instructions should the nurse include? - Answer "INSERT THE EARPIECE AT A DOWNWARD
ANGLE TOWARD YOUR NOSE"
- The nurse should insert the earpieces at a downward angle toward their nose because it helps
ensure that sounds are effectively transmitted to their eardrums.
A nurse is performing examination of the spine for an older adult client. The nurse should
identify that which of the following findings is common with age? - Answer KYPHOSIS
- Kyphosis - "hunchback" curvature of the spine is an abnormal angulation of the posterior curve
of the thoracic spine - usually resulting in osteoporosis. Most common in older adults and
increases with age.
A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over
the area with their fingers, then quickly releases it. The client reports increased pain on the
release of pressure. Which of the following findings should the nurse document? - Answer
REBOUND TENDERNESS
- The nurse should document that the client is experiencing rebound tenderness. Which is an
increase in pain when deep palpation over a tender area is released. Rebound tenderness in the
right lower quadrant at McBurney's point (one third the distance from the anterior iliac crest to
the umbilicus)is an indication of acute appendicitis.
A nurse is performing preparation to conduct a Romberg test on a client. The nurse should
explain to the client that the Romberg test is used to assess which of the following
characteristics? - Answer BALANCE
- Nurse should explain that the Romberg test is the most common test of balance
