Chapter 21: Physical Assessment - Nurselytic

Questions 49

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Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills

Chapter 21 : Physical Assessment Questions

Question 1 of 5

During palpation of the patient's abdomen, he flinches and tightens the abdominal muscles where you are palpating. This tightening of abdominal muscles is known as

Correct Answer: A

Rationale: Guarding refers to the involuntary tightening of abdominal muscles in response to pain or palpation, often indicating discomfort or pathology.

Question 2 of 5

What medical term would be appropriate to use when reporting that your patient is drowsy or mentally sluggish?

Correct Answer: A

Rationale: Lethargy is the appropriate term for a state of drowsiness or mental sluggishness.

Question 3 of 5

What type of assessment is performed on admission?

Correct Answer: B,C

Rationale: A comprehensive health assessment (
C) is typically performed on admission to gather baseline data, often including an initial head-to-toe shift assessment (
B) to evaluate all body systems.

Question 4 of 5

A patient was admitted yesterday with pneumonia. When auscultating his breath sounds you detect rales in the right lower lobe. How quickly should you reassess this abnormal finding?

Correct Answer: C

Rationale: Rales (crackles) indicate fluid in the lungs, requiring reassessment within 2 hours to monitor for worsening pneumonia or respiratory distress.

Question 5 of 5

A 5-year-old child has a fever of 104.4°F axillary. When should you reassess the child's temperature?

Correct Answer: A

Rationale: A high fever in a child requires reassessment within 60 minutes to monitor response to interventions and prevent complications like febrile seizures.

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