NUR 2092 / NUR2092 Health Assessment Exam 2 Quiz Bank | Questions and Answers with Rationale | Latest 2020 / 2021 | Rasmussen College

NUR 2092 / NUR2092 Health Assessment

Exam 2 Quiz Bank | Questions and Answers

with Rationale

1. The nurse will use which technique of assessment to determine the presence of crepitus,

swelling, and pulsations?

a. Palpation

b. Inspection

c. Percussion

d. Auscultation

RAT: Palpation applies the sense of touch to assess texture, temperature, moisture, organ

location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity,

crepitation, presence of lumps or masses, and the presence of tenderness or pain.

2. The nurse is preparing to use an otoscope for an examination. Which statement is true

regarding the otoscope? The otoscope:

a. Is often used to direct light onto the sinuses.

b. Uses a short, broad speculum to help visualize the ear.

c. Is used to examine the structures of the internal ear.

d. Directs light into the ear canal and onto the tympanic membrane.

RAT: The otoscope directs light into the ear canal and onto the tympanic membrane that

divides the external and middle ear. A short, broad speculum is used to visualize the

nares.

3. An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has

astigmatism and is nearsighted. The use of which of these techniques would indicate that

the examination is being correctly performed?

a. Using the large full circle of light when assessing pupils that are not dilated

b. Rotating the lens selector dial to the black numbers to compensate for astigmatism

c. Using the grid on the lens aperture dial to visualize the external structures of the eye

d. Rotating the lens selector dial to bring the object into focus

RAT: The ophthalmoscope is used to examine the internal eye structures. It can

compensate for nearsightedness or farsightedness, but it will not correct for astigmatism.

The grid is used to assess size and location of lesions on the fundus. The large full spot of

light is used to assess dilated pupils. Rotating the lens selector dial brings the object into

focus.

4. The nurse is unable to palpate the right radial pulse on a patient. The best action would be

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to:

a. Auscultate over the area with a fetoscope.

b. Use a goniometer to measure the pulsations.

c. Use a Doppler device to check for pulsations over the area.

d. Check for the presence of pulsations with a stethoscope.

RAT: Doppler devices are used to augment pulse or blood pressure measurements.

Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart

tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.

5. The nurse is preparing to perform a physical assessment. The correct action by the nurse

is reflected by which statement? The nurse:

a. Performs the examination from the left side of the bed.

b. Examines tender or painful areas first to help relieve the patient’s anxiety.

c. Follows the same examination sequence, regardless of the patient’s age or

condition.

d. Organizes the assessment to ensure that the patient does not change positions

too often.

RAT: The steps of the assessment should be organized to ensure that the patient does not

change positions too often. The sequence of the steps of the assessment may differ,

depending on the age of the person and the examiner’s preference. Tender or painful

areas should be assessed last.

6. A man is at the clinic for a physical examination. He states that he is “very anxious”

about the physical examination. What steps can the nurse take to make him more

comfortable?

a. Appear unhurried and confident when examining him.

b. Stay in the room when he undresses in case he needs assistance.

c. Ask him to change into an examining gown and to take off his undergarments.

d. Defer measuring vital signs until the end of the examination, which allows him time

to become comfortable.

RAT: Anxiety can be reduced by an examiner who is confident, self-assured, considerate,

and unhurried. Familiar and relatively nonthreatening actions, such as measuring the

person’s vital signs, will gradually accustom the person to the examination.

7. When performing a physical examination, safety must be considered to protect the

examiner and the patient against the spread of infection. Which of these statements

describes the most appropriate action the nurse should take when performing a physical

examination?

a. Washing one’s hands after removing gloves is not necessary, as long as the gloves

are still intact.

b. Hands are washed before and after every physical patient encounter.

c. Hands are washed before the examination of each body system to prevent the

spread of bacteria from one part of the body to another.

d. Gloves are worn throughout the entire examination to demonstrate to the patient

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concern regarding the spread of infectious diseases.

RAT: The nurse should wash his or her hands before and after every physical patient

encounter; after contact with blood, body fluids, secretions, and excretions; after contact

with any equipment contaminated with body fluids; and after removing gloves. Hands

should be washed after gloves have been removed, even if the gloves appear to be intact.

Gloves should be worn when potential contact with any body fluids is present.

8. The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of

these actions is most appropriate in this situation?

a. Washing hands, and contacting the physician

b. Continuing to examine the ulceration, and then washing hands

c. Washing hands, putting on gloves, and continuing with the examination of the

ulceration

d. Washing hands, proceeding with rest of the physical examination, and then

continuing with the examination of the leg ulceration

RAT: The examiner should wear gloves when the potential contact with any body fluids

is present. In this situation, the nurse should wash his or her hands, put on gloves, and

continue examining the ulceration.

9. During the examination, offering some brief teaching about the patient’s body or the

examiner’s findings is often appropriate. Which one of these statements by the nurse is

most appropriate?

a. “Your atrial dysrhythmias are under control.”

b. “You have pitting edema and mild varicosities.”

c. “Your pulse is 80 beats per minute, which is within the normal range.”

d. “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.”

RAT: The sharing of some information builds rapport, as long as the patient is able to

understand the terminology.

10. The nurse keeps in mind that the most important reason to share information and to offer

brief teaching while performing the physical examination is to help the:

a. Examiner feel more comfortable and to gain control of the situation.

b. Examiner to build rapport and to increase the patient’s confidence in him or

her.

c. Patient understand his or her disease process and treatment modalities.

d. Patient identify questions about his or her disease and the potential areas of patient

education.

RAT: Sharing information builds rapport and increases the patient’s confidence in the

examiner. It also gives the patient a little more control in a situation during which feeling

completely helpless is often present.

11. The nurse is examining an infant and prepares to elicit the Moro reflex at which time

during the examination?

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Version 2021
Category Exam (elaborations)
Pages 130
Language English
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