ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 27 : Health Assessment Questions
Question 1 of 5
A nursing student is learning to perform physical assessments. When will the student use the technique of palpation? Select all that apply.
Correct Answer: A,C,D
Rationale: During palpation, the nurse uses the sense of touch to compare bilateral pulses for symmetrical temperature, assess skin turgor, and check for enlarged lymph nodes. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds provide information about the location, shape, size, and density of tissues, such as dullness over a mass or fluid accumulation. Auscultation refers to listening with a stethoscope to sounds produced in the body; counting the apical pulse or auscultating heart sounds/murmurs are examples.
Question 2 of 5
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.
Question 3 of 5
The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing assessments can the nurse perform with the patient in this position? Select all that apply.
Correct Answer: B,C,D
Rationale: In the dorsal recumbent position, the patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles. Vital sign assessment should be done in the sitting position, and evaluating balance and gait is done with the patient in the standing position.
Question 4 of 5
A school nurse assesses adolescents' visual acuity using a Snellen eye chart. Which explanation does the nurse provide to the student whose vision is 20/40 in both eyes?
Correct Answer: C
Rationale: Normal vision is 20/20. The higher the denominator indicates increasingly worse vision; 20/40 vision indicates less than normal vision.
Question 5 of 5
The nurse is caring for a patient experiencing bronchospasm due to an exacerbation of asthma. During auscultation, the nurse anticipates the presence of which breath sound?
Correct Answer: B
Rationale: Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways, such as with bronchospasm found in asthma or COPD. Rhonchi are low-pitched, continuous sounds with a snoring quality, which may clear with coughing; they occur when air passes through secretions. Crackles are discontinuous bubbling, cracking, or popping, low- to high-pitched sounds, that occur when air passes through fluid in the airways.