For most body systems, in what order does the nurse use the physical examination techniques?
Inspection, palpation, percussion, auscultation
✓
Palpation, inspection, auscultation, percussion
Auscultation, percussion, palpation, inspection
Percussion, inspection, palpation, auscultation
Correct Answer
Inspection, palpation, percussion, auscultation
Most systems are examined by looking first, then feeling, then tapping, then listening, so that each step builds on what was already observed. Palpation, inspection, auscultation, percussion touches the patient before looking. Auscultation, percussion, palpation, inspection leaves the visual survey until last. Percussion, inspection, palpation, auscultation starts with tapping before the area has been observed.
Category: Examination Techniques
Question 2
Why does the nurse listen to the abdomen before percussing or palpating it?
Bowel sounds can only be heard after the abdomen is touched
Pressing and tapping can change bowel activity and alter the sounds
✓
Listening is the most uncomfortable step and is done early
Percussion and palpation require a stethoscope already in place
Correct Answer
Pressing and tapping can change bowel activity and alter the sounds
The abdomen is the main exception to the usual order: auscultation follows inspection because manipulating the abdomen can stimulate or alter bowel sounds. Bowel sounds can only be heard after the abdomen is touched is false, because they are produced by normal gut movement. Listening is the most uncomfortable step and is done early is wrong because auscultation is painless. Percussion and palpation require a stethoscope already in place is wrong because both are done with the hands.
Category: Examination Techniques
Question 3
A patient reports pain in the lower right abdomen. When should the nurse palpate that area?
First, to locate the source of pain quickly
Only before listening to bowel sounds
Last, after the areas that are not painful
✓
Never, because painful areas are not palpated
Correct Answer
Last, after the areas that are not painful
Painful areas are examined last so the patient does not tense the abdominal muscles, which would make the rest of the exam unreliable, and so the patient is not hurt early. First, to locate the source of pain quickly causes guarding that hides other findings. Only before listening to bowel sounds reverses the abdominal sequence. Never, because painful areas are not palpated is wrong because gentle palpation of a tender area gives important information.
Category: Examination Techniques
Question 4
Which part of the hand is best for judging the temperature of a patient's skin?
The fingertips
The palm near the little finger
The knuckles
The back of the hand
✓
Correct Answer
The back of the hand
The skin on the back of the hand is thin and sensitive to warmth and coolness, so it is used to compare skin temperature. The fingertips are best for fine discrimination, such as texture, pulses, and size of a mass. The palm near the little finger best detects vibration. The knuckles are not used to judge skin temperature.
Category: Examination Techniques
Question 5
Percussing over the liver normally produces which sound?
Dullness
✓
Tympany
Resonance
Hyperresonance
Correct Answer
Dullness
A dense, solid organ such as the liver produces a soft, thudlike dull sound. Tympany is the drumlike sound heard over gas-filled bowel. Resonance is the hollow sound of normal, air-filled lung. Hyperresonance is an abnormally booming sound heard when too much air is present, as in overinflated lungs.
Category: Examination Techniques
Question 6
While auscultating, the nurse hears loud, high-pitched, hollow breath sounds over the outer lung fields, where only soft sounds are normally heard. What does this finding suggest?
Narrowing of the small airways
Consolidated lung tissue, as in pneumonia
✓
Air trapped in the pleural space
Normal airflow through healthy lungs
Correct Answer
Consolidated lung tissue, as in pneumonia
These are bronchial breath sounds, which are normal only over the trachea; heard over the outer lung fields, they mean the lung tissue has become dense, as in pneumonia, and carries sound to the chest wall more clearly. Narrowing of the small airways produces wheezes. Air trapped in the pleural space diminishes or eliminates breath sounds over the area. Normal airflow through healthy lungs produces soft, low-pitched vesicular sounds over the outer fields.
Category: Lung and Heart Findings
Question 7
While auscultating the lung bases, the nurse hears brief, discontinuous popping sounds. What do these sounds suggest?
Air trapped in the pleural space
Inflamed pleural surfaces rubbing together
Fluid in the small airways and alveoli
✓
Normal airflow through healthy lungs
Correct Answer
Fluid in the small airways and alveoli
Crackles are short popping sounds made as air moves through fluid or as collapsed small airways snap open, and they are common with fluid overload and pneumonia. Air trapped in the pleural space reduces or eliminates breath sounds over the area. Inflamed pleural surfaces rubbing together create a grating friction rub. Normal airflow through healthy lungs produces soft vesicular sounds without added noises.
Category: Lung and Heart Findings
Question 8
The nurse presses a thumb into the skin over a patient's ankle, and a dent remains after the thumb is removed. How is this finding documented?
Nonpitting edema
Poor skin turgor
Delayed capillary refill
Pitting edema
✓
Correct Answer
Pitting edema
A dent that remains after pressure means excess fluid in the tissues has been pushed aside, which is pitting edema and is common with heart failure and kidney problems. Nonpitting edema is swelling that does not leave a dent. Poor skin turgor is skin that stays tented after it is pinched. Delayed capillary refill is slow return of color to a nail bed after it is pressed.
Category: Skin and Circulation
Question 9
When the nurse gently pinches the skin on a patient's chest, the skin stays raised for a moment instead of flattening right away. What does this finding most likely suggest?
Dehydration
✓
Fluid overload
Low oxygen in the blood
Liver disease
Correct Answer
Dehydration
Skin that stays tented shows poor turgor, a sign of fluid volume deficit; because skin loses elasticity with age, this sign is less reliable in older adults. Fluid overload makes tissues swollen and tight rather than slow to recoil. Low oxygen in the blood shows up as bluish color, not tenting. Liver disease may cause yellow skin but does not cause tenting.
Category: Skin and Circulation
Question 10
A patient has enlarged, rounded fingertips with nails that curve over them. What does this finding suggest?
A recent minor hand injury
Long-term low oxygen levels
✓
Short-term dehydration
Normal aging of the nails
Correct Answer
Long-term low oxygen levels
Clubbing develops slowly in conditions that cause chronic hypoxia, such as long-standing lung or heart disease, so it points to a chronic rather than acute problem. A recent minor hand injury would cause localized swelling or bruising, not clubbing. Short-term dehydration does not change nail shape. Normal aging of the nails causes ridges or thickening, not clubbing.
Category: Skin and Circulation
Question 11
A patient admitted after a head injury has one pupil that is newly larger than the other and slow to react to light. What should the nurse do?
Recheck the pupils at the next scheduled assessment
Dim the room lights and recheck in the morning
Report the change to the provider immediately
✓
Document the change as an expected finding
Correct Answer
Report the change to the provider immediately
A new difference in pupil size and reaction after a head injury can signal rising pressure inside the skull and needs immediate reporting. Recheck the pupils at the next scheduled assessment delays care for a possibly life-threatening change. Dim the room lights and recheck in the morning wastes critical time. Document the change as an expected finding is wrong because pupils are normally equal and briskly reactive.
Category: Head and Neuro Findings
Question 12
A nurse is listening over a patient's carotid artery for a bruit. Which technique is correct?
Ask the patient to breathe rapidly while listening
Palpate both carotid arteries at the same time
Percuss over the artery and listen for dullness
Place the bell of the stethoscope lightly on the skin
✓
Correct Answer
Place the bell of the stethoscope lightly on the skin
A bruit is a low-pitched sound, and the bell held with light pressure picks up low-pitched sounds best. Ask the patient to breathe rapidly while listening adds breath noise that can hide a bruit; the patient instead holds the breath briefly. Palpate both carotid arteries at the same time can reduce blood flow to the brain and is avoided. Percuss over the artery and listen for dullness is not a way to detect turbulent blood flow.
Category: Lung and Heart Findings
Question 13
Which item recorded in a patient's social history is a risk factor for poor health?
Unstable housing
✓
Steady employment
A close network of friends
Regular physical activity
Correct Answer
Unstable housing
Unstable housing or homelessness makes it harder to rest, eat well, store medications, and keep appointments, so it is a social risk factor that shapes the care plan. Steady employment is a protective factor that supports financial security and access to care. A close network of friends is a protective factor that helps patients cope. Regular physical activity is a health-promoting habit.
Category: Health History
Question 14
A patient with advanced dementia says she takes no medications, but her records list several daily drugs. What should the nurse do?
Document that she takes no medications
Confirm the medication history with family and the records
✓
Tell her that she is not being truthful
Stop all medications until she remembers them
Correct Answer
Confirm the medication history with family and the records
A patient with cognitive decline may not be a reliable historian, so the nurse verifies the history with other sources such as family, medication bottles, and records. Document that she takes no medications records information that is probably wrong. Tell her that she is not being truthful assumes intent when the problem is memory. Stop all medications until she remembers them is unsafe and outside the nurse's authority.
Category: Health History
Question 15
A patient arrives on the unit reporting new shortness of breath. Which assessment should the nurse perform first?
A comprehensive assessment of every system
A complete family health history
A focused respiratory assessment
✓
A review of the patient's diet and activity
Correct Answer
A focused respiratory assessment
A focused assessment targets the system tied to the chief complaint so an urgent problem is found and treated quickly. A comprehensive assessment of every system takes too long when breathing is the immediate concern. A complete family health history does not address the current problem. A review of the patient's diet and activity is useful later but not first.
Category: Assessment Types and Safety
Question 16
A patient has a weeping rash on the leg. Which question is open-ended?
Did you tell your doctor about the rash?
Is the rash itchy?
Have you had this rash before?
What can you tell me about the rash on your leg?
✓
Correct Answer
What can you tell me about the rash on your leg?
An open-ended question invites the patient to describe the problem in their own words and often reveals details the nurse did not think to ask. Did you tell your doctor about the rash? allows only yes or no and can make the patient feel judged. Is the rash itchy? limits the answer to one symptom. Have you had this rash before? is answered with yes or no.
Category: Patient Communication
Question 17
Which action by a nurse is a boundary violation?
Accepting a cash gift from a patient
✓
Sitting at the patient's eye level during an interview
Introducing oneself by name and role
Touching the patient's wrist to check a pulse
Correct Answer
Accepting a cash gift from a patient
Accepting gifts or money blurs the line between a professional and a personal relationship, and the nurse is responsible for keeping that line clear. Sitting at the patient's eye level during an interview is a therapeutic way to show attention. Introducing oneself by name and role begins therapeutic communication. Touching the patient's wrist to check a pulse is purposeful, therapeutic touch.
Category: Patient Communication
Question 18
An older adult leans forward and asks the nurse to repeat questions, and says his hearing aids were left at home. How should the nurse adjust the interview?
Speak loudly into the ear he hears better with
Face him in a quiet, well-lit room and speak clearly without shouting
✓
Ask a family member to answer for him
Switch to yes-or-no questions for the whole history
Correct Answer
Face him in a quiet, well-lit room and speak clearly without shouting
Facing the patient in good light lets him see the nurse's face and lips, a quiet room removes competing noise, and clear speech is easier to follow than shouting, which distorts sound. Speak loudly into the ear he hears better with distorts words and blocks his view of the nurse's face. Ask a family member to answer for him takes away his voice when he can still take part. Switch to yes-or-no questions for the whole history limits the information he can give.
Category: Patient Communication
Question 19
Which step is part of the safety and surroundings assessment?
Listening to bowel sounds in each quadrant
Checking the pupils' response to light
Confirming the patient's identity with the wristband
✓
Listening to breath sounds at the lung bases
Correct Answer
Confirming the patient's identity with the wristband
The safety assessment checks identification, allergy bands, fall risk, ambulatory aids, bed position, side rails, call light access, and other hazards to prevent injury and errors. Listening to bowel sounds in each quadrant is part of the abdominal assessment. Checking the pupils' response to light is part of the eye and neurologic assessment. Listening to breath sounds at the lung bases is part of the respiratory assessment.
Category: Assessment Types and Safety
Question 20
Which part of the health history explores details of the current problem, such as when it started, how severe it is, and what makes it better or worse?
Review of systems
Past medical history
Social history
History of present illness
✓
Correct Answer
History of present illness
The history of present illness adds detail to the chief complaint, including onset, duration, intensity, aggravating and relieving factors, and associated symptoms. Review of systems checks each body system for other symptoms. Past medical history covers earlier and chronic conditions. Social history covers lifestyle, living situation, and habits.
Category: Health History