NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz
Bank | Questions and Answers with Rationale | Latest
| Rasmussen College
The nurse would use bimanual palpation technique in which situation?
a.
Palpating the thorax of an infant
b.
Palpating the kidneys and uterus
c.
Assessing pulsations and vibrations
d.
Assessing the presence of tenderness and pain
RAT: Bimanual palpation requires the use of both hands to envelop or capture certain
body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not
appropriate for bimanual palpation.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion
is to assess the of the underlying tissue.
a.
Turgor
b.
Texture
c.
Density
d.
Consistency
RAT: Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation.
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed?
a.
Percussing once over each area
b.
Quickly lifting the striking finger after each stroke
c.
Striking with the fingertip, not the finger pad
d.
Using the wrist to make the strikes, not the arm
RAT: For percussion, the nurse should percuss two times over each location. The striking
,finger should be quickly lifted because a resting finger damps off vibrations. The tip of
the striking finger should make contact, not the pad of the finger. The wrist must be
relaxed and is used to make the strikes, not the arm.
, When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should:
a.
Consider this a normal finding.
b.
Palpate this area for an underlying mass.
c.
Reposition the hands, and attempt to percuss in this area again.
d.
Consider this finding as abnormal, and refer the patient for additional treatment.
RAT: Percussion over relatively dense organs, such as the liver or spleen, will produce a
dull sound. The other responses are not correct.
The nurse is unable to identify any changes in sound when percussing over the abdomen
of an obese patient. What should the nurse do next?
a.
Ask the patient to take deep breaths to relax the abdominal musculature.
b.
Consider this finding as normal, and proceed with the abdominal assessment.
c.
Increase the amount of strength used when attempting to percuss over the
abdomen.
d.
Decrease the amount of strength used when attempting to percuss over
the abdomen.
RAT: The thickness of the person’s body wall will be a factor. The nurse needs a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the
blow determines the loudness of the note. The other actions are not correct.
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-
year-old child. The nurse should:
a.
Palpate over the area for increased pain and tenderness.
b.
Ask the child to take shallow breaths, and percuss over the area again.
c.
Immediately refer the child because of an increased amount of air in the lungs.
d.
Consider this finding as normal for a child this age, and proceed with the
examination.
RAT: Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and
long in duration are normal over a child’s lung.
, A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen, which
of these actions is the best for the nurse to take when further assessing the patient?
a.
Count the patient’s respirations.
b.
Bilaterally percuss the thorax, noting any differences in percussion tones.
c.
Call for a chest x-ray study, and wait for the results before beginning an
assessment.
d.
Inspect the thorax for any new masses and bleeding associated with respirations.
RAT: Percussion is always available, portable, and offers instant feedback regarding
changes in underlying tissue density, which may yield clues of the patient’s physical
Bank | Questions and Answers with Rationale | Latest
| Rasmussen College
The nurse would use bimanual palpation technique in which situation?
a.
Palpating the thorax of an infant
b.
Palpating the kidneys and uterus
c.
Assessing pulsations and vibrations
d.
Assessing the presence of tenderness and pain
RAT: Bimanual palpation requires the use of both hands to envelop or capture certain
body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not
appropriate for bimanual palpation.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion
is to assess the of the underlying tissue.
a.
Turgor
b.
Texture
c.
Density
d.
Consistency
RAT: Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation.
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed?
a.
Percussing once over each area
b.
Quickly lifting the striking finger after each stroke
c.
Striking with the fingertip, not the finger pad
d.
Using the wrist to make the strikes, not the arm
RAT: For percussion, the nurse should percuss two times over each location. The striking
,finger should be quickly lifted because a resting finger damps off vibrations. The tip of
the striking finger should make contact, not the pad of the finger. The wrist must be
relaxed and is used to make the strikes, not the arm.
, When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should:
a.
Consider this a normal finding.
b.
Palpate this area for an underlying mass.
c.
Reposition the hands, and attempt to percuss in this area again.
d.
Consider this finding as abnormal, and refer the patient for additional treatment.
RAT: Percussion over relatively dense organs, such as the liver or spleen, will produce a
dull sound. The other responses are not correct.
The nurse is unable to identify any changes in sound when percussing over the abdomen
of an obese patient. What should the nurse do next?
a.
Ask the patient to take deep breaths to relax the abdominal musculature.
b.
Consider this finding as normal, and proceed with the abdominal assessment.
c.
Increase the amount of strength used when attempting to percuss over the
abdomen.
d.
Decrease the amount of strength used when attempting to percuss over
the abdomen.
RAT: The thickness of the person’s body wall will be a factor. The nurse needs a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the
blow determines the loudness of the note. The other actions are not correct.
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-
year-old child. The nurse should:
a.
Palpate over the area for increased pain and tenderness.
b.
Ask the child to take shallow breaths, and percuss over the area again.
c.
Immediately refer the child because of an increased amount of air in the lungs.
d.
Consider this finding as normal for a child this age, and proceed with the
examination.
RAT: Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and
long in duration are normal over a child’s lung.
, A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen, which
of these actions is the best for the nurse to take when further assessing the patient?
a.
Count the patient’s respirations.
b.
Bilaterally percuss the thorax, noting any differences in percussion tones.
c.
Call for a chest x-ray study, and wait for the results before beginning an
assessment.
d.
Inspect the thorax for any new masses and bleeding associated with respirations.
RAT: Percussion is always available, portable, and offers instant feedback regarding
changes in underlying tissue density, which may yield clues of the patient’s physical
