Health Assessment and Physical Examination
A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for
a patient, the new graduate nurse begins to explain to the patient the purpose of
completing a physical assessment. Which statement made by the new graduate nurse
requires the preceptor to intervene?
a."I will use the information from my assessment to figure out if your antihypertensive
medication is working effectively."
b."Nursing assessment data are used only to provide information about the effectiveness of
your medical care."
c."Nurses use data from their patient's physical assessment to determine a patient's
educational needs."
d."Information gained from physical assessment helps nurses better understand their
patients' emotional needs." - -ANS: B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's
care, not just the patient's medical care. Assessment data help to evaluate the
effectiveness of medications and to determine a patient's health care needs, including the
need for patient education. Nurses also use assessment data to identify patients'
psychosocial and cultural needs.
2. Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse
next enters the patient's room and identifies self, washes hands with soap, and states the
purpose of the visit. The nurse performs proper identification of the patient before
auscultating the patient's lungs. Which critical health assessment step should the nurse
have performed?
a.Running warm water over stethoscope
b.Draping stethoscope around the neck
, Health Assessment and Physical Examination
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol - -ANS: D
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is
not clean is used. The stethoscope should be cleaned before use on each patient with
isopropyl alcohol. Running water over the stethoscope does not kill bacteria. Betadine is
an inappropriate cleaning solution and may damage the equipment. Draping the
stethoscope around the neck is not advised.
3. A nurse is preparing to perform a complete physical examination on a weak, older-adult
patient with bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims'
c. Supine
d. Lateral recumbent - -ANS: C
Supine is the most normally relaxed position. If the patient becomes short of breath easily,
raise the head of the bed. Supine position would be easiest for a weak, older-adult person
during the examination. Lateral recumbent and prone positions cause respiratory difficulty
for any patient with respiratory difficulties. Sims' position is used for assessment of the
rectum and the vagina.
4. A nurse is conducting Weber's test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient's forehead.
, Health Assessment and Physical Examination
b. Place a vibrating tuning fork on the patient's mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient's degree of joint movement to the normal level. - -ANS: A
During Weber's test (lateralization of sound), the nurse places the vibrating tuning fork in
the middle of the patient's forehead. During a Rinne test (comparison of air and bone
conduction), the nurse places a vibrating tuning fork on the patient's mastoid process and
compares the length of time air and bone conduction is heard. Comparing the patient's
degree of joint movement to the normal level is a test for range of motion.
5. A head and neck physical examination is completed on a 50-year-old female patient. All
physical findings are normal except for fine brittle hair. Which laboratory test will the nurse
expect to be ordered, based upon the physical findings?
a.Oxygen saturation
b. Liver function test
c. Carbon monoxide
d. Thyroid-stimulating hormone test - -ANS: D
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a
patient who has jaundice. Oxygen saturation will be used for cyanosis. Cherry-colored lips
indicate carbon monoxide poisoning.
A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for
a patient, the new graduate nurse begins to explain to the patient the purpose of
completing a physical assessment. Which statement made by the new graduate nurse
requires the preceptor to intervene?
a."I will use the information from my assessment to figure out if your antihypertensive
medication is working effectively."
b."Nursing assessment data are used only to provide information about the effectiveness of
your medical care."
c."Nurses use data from their patient's physical assessment to determine a patient's
educational needs."
d."Information gained from physical assessment helps nurses better understand their
patients' emotional needs." - -ANS: B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's
care, not just the patient's medical care. Assessment data help to evaluate the
effectiveness of medications and to determine a patient's health care needs, including the
need for patient education. Nurses also use assessment data to identify patients'
psychosocial and cultural needs.
2. Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse
next enters the patient's room and identifies self, washes hands with soap, and states the
purpose of the visit. The nurse performs proper identification of the patient before
auscultating the patient's lungs. Which critical health assessment step should the nurse
have performed?
a.Running warm water over stethoscope
b.Draping stethoscope around the neck
, Health Assessment and Physical Examination
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol - -ANS: D
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is
not clean is used. The stethoscope should be cleaned before use on each patient with
isopropyl alcohol. Running water over the stethoscope does not kill bacteria. Betadine is
an inappropriate cleaning solution and may damage the equipment. Draping the
stethoscope around the neck is not advised.
3. A nurse is preparing to perform a complete physical examination on a weak, older-adult
patient with bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims'
c. Supine
d. Lateral recumbent - -ANS: C
Supine is the most normally relaxed position. If the patient becomes short of breath easily,
raise the head of the bed. Supine position would be easiest for a weak, older-adult person
during the examination. Lateral recumbent and prone positions cause respiratory difficulty
for any patient with respiratory difficulties. Sims' position is used for assessment of the
rectum and the vagina.
4. A nurse is conducting Weber's test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient's forehead.
, Health Assessment and Physical Examination
b. Place a vibrating tuning fork on the patient's mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient's degree of joint movement to the normal level. - -ANS: A
During Weber's test (lateralization of sound), the nurse places the vibrating tuning fork in
the middle of the patient's forehead. During a Rinne test (comparison of air and bone
conduction), the nurse places a vibrating tuning fork on the patient's mastoid process and
compares the length of time air and bone conduction is heard. Comparing the patient's
degree of joint movement to the normal level is a test for range of motion.
5. A head and neck physical examination is completed on a 50-year-old female patient. All
physical findings are normal except for fine brittle hair. Which laboratory test will the nurse
expect to be ordered, based upon the physical findings?
a.Oxygen saturation
b. Liver function test
c. Carbon monoxide
d. Thyroid-stimulating hormone test - -ANS: D
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a
patient who has jaundice. Oxygen saturation will be used for cyanosis. Cherry-colored lips
indicate carbon monoxide poisoning.
