Question 1

During a physical assessment,the nurse listens for adventitious lung sounds.Crackles are classified as fine,medium,or coarse and are most often heard:

Accepted Answer

Crackles are usually heard during inspiration.

Question 2

When performing a physical examination of a patient,the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen.This technique is:

Accepted Answer

Deep palpation is used to detect tenderness or masses of the abdomen.

Question 3

When auscultating the thorax,the suggested sequence for a systematic approach is to begin with the:

Accepted Answer

The suggested sequence for a systematic auscultation of the thorax is to begin with the apices.

Question 4

An older adult patient is being assessed for skin turgor.The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised.The nurse recognizes this could be caused by:

Accepted Answer

Dehydration results in decreased skin turgor.

Question 5

The nurse is obtaining a history of a patient's present illness.The PQRST system is used for the interview.In this system,the R stands for:

Accepted Answer

In the PQRST system,the R stands for region.

Question 6

The nurse is performing auscultation of breath sounds on a respiratory patient.The sounds heard on inspiration and expiration are low-pitched,coarse,gurgling,and have a snoring sound.These are identified as:

Accepted Answer

Sonorous wheezes have a low-pitched,coarse,gurgling,snoring quality and usually indicate the presence of mucus in the trachea and large airways.

Question 7

During a head-to-toe assessment,the nurse assesses the patient's abdomen.Which area should the nurse assess next?

Accepted Answer

When performing a head-to-toe assessment,the nurse begins with a neurological assessment,then assesses the skin,hair,head,and neck,including the eyes,ears,nose,and mouth.The chest,back,arms,abdomen,perineal area,legs,and feet are examined in that order.

Question 8

Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope.The "lubb" sound is caused by the:

Accepted Answer

The "lubb-dupp" sound of the heart is caused by the closing of the AV and semilunar valves,respectively.

Question 9

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

Accepted Answer

Symptoms are subjective indications of illness that are perceived by the patient.Examples of symptoms are pain,nausea,vertigo,pruritus,diplopia,numbness,and anxiety.The nurse is unaware of symptoms unless the patient describes the sensation.Symptoms are referred to as subjective data.Chest pain is the only subjective assessment finding.All other options are examples of objective data.

Question 10

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective? The patient:

Accepted Answer

Objective data can be seen,heard,measured,or felt by the examiner.It is information that is observable and measurable and can be verified by more than one person.Anxiety is the only objective assessment finding.All other options are examples of subjective data.

Question 11

A patient has edema of the lower extremities.The nurse is assessing whether it is pitting and to what degree.After pressing the skin against a bony prominence for 5 seconds,the nurse identifies 2+ pitting edema because the edema disappears in:

Accepted Answer

The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.

Question 12

During a head-to-toe assessment,the nurse assesses the patient's perineal area.Which area should the nurse assess next?

Accepted Answer

When performing a head-to-toe assessment,the nurse begins with a neurological assessment,then assesses the skin,hair,head,and neck,including the eyes,ears,nose,and mouth.The chest,back,arms,abdomen,perineal area,legs,and feet are examined in that order.

Question 13

The nurse assesses a patient for capillary refill.After the fingernail is compressed for 5 seconds,the refill time should be fewer than:

Accepted Answer

Capillary refill should take fewer than 3 seconds.

Question 14

When performing a nursing physical assessment,the nurse uses a head-to-toe approach.When using this method,the nurse begins with a:

Accepted Answer

When performing a head-to-toe assessment,the nurse begins with a neurological assessment.

Question 15

When performing a head-to-toe assessment,the nurse should begin by assessing the patient's:

Accepted Answer

When performing a head-to-toe assessment,the nurse begins with a neurological assessment,then assesses the skin,hair,head,and neck,including the eyes,ears,nose,and mouth.The chest,back,arms,abdomen,perineal area,legs,and feet are examined in that order.

Question 16

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

Accepted Answer

Symptoms are subjective indications of illness that are perceived by the patient.Examples of symptoms are pain,nausea,vertigo,pruritus,diplopia,numbness,and anxiety.The nurse is unaware of symptoms unless the patient describes the sensation.Symptoms are referred to as subjective data.Pruritis is the only subjective assessment finding.All other options are examples of objective data.

Question 17

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope.The normal rate of bowel sounds per minute is:

Accepted Answer

The normal rate of bowel sounds per minute is 4-32.

Question 18

Various techniques are used by the nurse when performing a physical assessment.One of these techniques is percussion.Percussion is used to determine:

Accepted Answer

The sounds indicate the density of the underlying tissue.

Question 19

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

Accepted Answer

Symptoms are subjective indications of illness that are perceived by the patient.Examples of symptoms are pain,nausea,vertigo,pruritus,diplopia,numbness,and anxiety.The nurse is unaware of symptoms unless the patient describes the sensation.Symptoms are referred to as subjective data.Diplopia is the only subjective assessment finding.All other options are examples of objective data.

Question 20

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective data?

Accepted Answer

Objective data can be seen,heard,measured,or felt by the examiner.It is information that is observable and measurable and can be verified by more than one person.Expectoration of red-tinged sputum is the only objective assessment finding.All other options are examples of subjective data.

Quiz 5: Physical Assessment

During a physical assessment,the nurse listens for adventitious lung sounds.Crackles are classified as fine,medium,or coarse and are most often heard:

When performing a physical examination of a patient,the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen.This technique is:

When auscultating the thorax,the suggested sequence for a systematic approach is to begin with the:

An older adult patient is being assessed for skin turgor.The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised.The nurse recognizes this could be caused by:

The nurse is obtaining a history of a patient's present illness.The PQRST system is used for the interview.In this system,the R stands for:

The nurse is performing auscultation of breath sounds on a respiratory patient.The sounds heard on inspiration and expiration are low-pitched,coarse,gurgling,and have a snoring sound.These are identified as:

During a head-to-toe assessment,the nurse assesses the patient's abdomen.Which area should the nurse assess next?

Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope.The "lubb" sound is caused by the:

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective? The patient:

A patient has edema of the lower extremities.The nurse is assessing whether it is pitting and to what degree.After pressing the skin against a bony prominence for 5 seconds,the nurse identifies 2+ pitting edema because the edema disappears in:

During a head-to-toe assessment,the nurse assesses the patient's perineal area.Which area should the nurse assess next?

The nurse assesses a patient for capillary refill.After the fingernail is compressed for 5 seconds,the refill time should be fewer than:

When performing a nursing physical assessment,the nurse uses a head-to-toe approach.When using this method,the nurse begins with a:

When performing a head-to-toe assessment,the nurse should begin by assessing the patient's:

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope.The normal rate of bowel sounds per minute is:

Various techniques are used by the nurse when performing a physical assessment.One of these techniques is percussion.Percussion is used to determine:

A nurse is gathering subjective data when admitting a patient.Which assessment finding is considered subjective data? The patient:

A nurse is gathering objective data when admitting a patient.Which assessment finding is considered objective data?