Clinical Nursing Skills And Techniques by Perry 8th Edition – Test Bank

Clinical Nursing Skills And Techniques by Perry 8th Edition – Test Bank

Chapter 11
Physical Assessment
Test Item File
1. Define the four techniques of assessment.
a.
b.
c.
d.
2. The normal sequence of the physical examination should be
a. Palpation, percussion, inspection, auscultation.
b. Inspection, palpation, percussion, auscultation.
c. Percussion, auscultation, palpation, inspection.
d. Auscultation, palpation, percussion, inspection.
3. When performing a complete physical assessment, you begin by obtaining a health history. This includes
a.
b.
c.
d.
e.
f.
g.
4. The three parameters you would use to assess a client’s coma level are:
a.
b.
c.
5. The most reliable index for determining cerebral function is the .
6. When a client experiences decorticate or abnormal flexor posturing, in what position do you expect to find his or her extremities?
7. What does decerebrate posturing tell you about the client’s condition?

8. When checking the client’s pupils, list four aspects that are observed.
a.
b.
c.
d.
9. Explain briefly how to test a client’s ability to either flex or extend his or herarms or legs.
10. You are to assess a client’s reflexes. Identify the four major reflexes.
a.
b.
c.
d.
11. A normal plantar response is characterized by
a. Toes going up.
b. Toes going down.
c. Client laughing.
d. Toes spreading.
12. To assess the first cranial nerve, the examiner uses
a. Aromatic substances.
b. A penlight.
c. An ophthalmoscope.
d. A tuning fork.
13. Distinguish between 4+ and 1+ on the grading scale used when evaluating reflexes.

14. List four factors to be used when assessing the client’s skin condition.
a.
b.
c.
d.
15. Indicate locations on the diagram where breath sounds should be auscultated.
16. A Cheyne–Stokes pattern of breathing is characterized by
a. Sustained deep breathing.
b. An erratic breathing pattern.
c. Decreased respiratory rate.
d. Apnea alternating with hyperventilation.
17. Match the defining characteristics from column B with the appropriate breath sound in column A.
Column A Column B
a. Vesicular _______ 1. Heard over mainstem bronchi
b. Bronchovesicular _______ 2. Expiratory phase twice as long as inspiratory phase
c. Bronchial _______ 3. Low to medium pitch sound
_______ 4. High pitch and amplitude
_______ 5. Inspiration and expiration equal in duration
_______ 6. Soft, whooshing quality to sound
_______ 7. Inspiration two to three times longer than expiration
_______ 8. Moderate to high pitch
_______ 9. Heard over trachea above sternal notch
_______ 10. Heard over lung parenchyma
18. Label the areas indicated by circles on the diagram where the four heart valves are best auscultated.
a.
b.
c.
d.
19. While conducting a cardiac assessment, what position is best for hearing the S1 and S2 heart sounds?
20. Describe the significance of S3 and S4 heart sounds and how they are most easily heard.

21. When apical pulse is greater than carotid pulse, it indicates

22. The sequence for abdominal examination techniques is
a. Palpation, percussion, inspection, auscultation.
b. Inspection, auscultation, palpation, percussion.
c. Percussion, auscultation, palpation, inspection.
d. Auscultation, palpation, percussion, inspection.
23. Discuss the possible clinical findings of a client with hyperactive versus hypoactive bowel.

24. Five components of urine are assessed when abnormalities of the urinary tract are suspected. List the five components.
a.
b.
c.
d.
e.
25. Two major factors observed during a genital assessment include
a.
b.
26. For a mental health assessment, match the normal response in column B with the assessment modality in column A.
_______ Column A Column B
_______ a. Thought processes and perception 1. Correct response to questions
_______ 2. Complete digit span
_______ b. Thought content and mental trend 3. Aware of time, place, person
_______ 4. Understands inner nature of a problem
_______ c. Memory
_______ d. Judgment 5. Able to concentrate
_______ e. Awareness 6. Realistic interpretation of events
_______ f. Intelligence
27. The client has an injury to the seventh cranial nerve. Your assessment should identify an abnormality in
a. Closing the eyelid.
b. Trapezius muscle movement.
c. Hearing.
d. Tongue control.
28. Bronchovesicular breath sounds are heard normally over the
a. Lung base.
b. Trachea above the sternal notch.
c. Mainstem bronchi below the clavicle.
d. Entire lung parenchyma.
29. An S2 heart sound represents
a. Closure of the aortic valve.
b. Closure of the mitral valve.
c. An atrial gallop.
d. A ventricular gallop.
30. The tricuspid valve sound is best heard at the
a. Second intercostal space, left sternal border.
b. Second intercostal space at the sternal border.
c. Midclavicular line, fifth intercostal space.
d. Left, fifth intercostal space at sternal border.
31. Which of the following statements is true regarding changes in assessment findings for the geriatric client?
a. Ciliary activities increase, leading to increased mucous production.
b. Increased ability to retain water.
c. Decreased vascular fragility.
d. Decreased number and size of sweat glands.
32. LVN/LPNs are allowed to complete physical assessments on all clients, from admission to discharge. They only need to report the changes in findings to the RN.
a. True
b. False
33. When completing an obstetrical assessment, Leopold’s maneuver is often completed. List the rationale for each maneuver.
a. First maneuver
b. Second maneuver
c. Third maneuver
d. Fourth maneuver
34. When completing the Apgar score for a newborn, give the total score for a newborn with:
a. Heart tone over 100
b. Respiratory effort, slow and irregular
c. Muscle tone active, motion
d. Reflex irritability, vigorous cry
e. Color, all pink
Total score is
ANSWERS
Content Examination
1. a. Inspection—observe characteristics of the client.
b. Auscultation—listen with stethoscope to heart, lung, bowel sounds.
c. Palpation—use hands to determine abnormal sounds, organ displacement, chest expansion.
d. Percussion—tapping body lightly with hands and fingers to detect abnormalities.
2. b
3. a. Biographic information.
b. Chief complaint.
c. Present health status or illness.
d. Health history.
e. Family history.
f. Psychosocial factors.
g. Nutrition.
4. a. Motor response.
b. Verbal response.
c. Eye opening.
5. Level of consciousness.
6. Legs and feet extended; arms internally rotated and flexed on chest.
7. The client has a lesion in the diencephalon, pons, or midbrain.
8. Size, shape, equality, reaction to light.
9. Assess flexion and extension strength in extremities (four possible answers).
a. Stand in front of client, place your hand in front of client, and ask client to push your hand away.
b. Place your hand on client’s forearm and ask client to pull his or her arm upward.
c. Position client’s leg with knee flexed and foot resting on bed; as you try to extend leg, ask client to keep his or her foot down.
d. Place one hand on client’s knee and one hand on client’s ankle; ask client to straighten his or her leg as you apply resistant force to knee and ankle.
10. Four major reflexes:
a. Blink reflex: Hold client’s eyelid open. Approach client’s eye unexpectedly from side of head or brush client’s eyelashes.
b. Gag and swallow reflex: Open client’s mouth and hold tongue down with tongue blade. Touch back of pharynx on each side with applicator stick.
c. Plantar response (Babinski reflex): Run top of pen along outer lateral aspect from heel to little toe of client’s foot. Continue tracing a line across ball of foot toward great toe.
d. Deep tendon reflex: Ask client to relax. Position limb to be assessed so that muscle is somewhat stretched. Using reflex hammer, strike tendon quickly while applying additional tendon stretch. Assess according to scale.
11. b
12. a
13. Grading Scale
4+ Hyperactive (indicative of disease state).
3+ More brisk than usual but not indicative of disease state.
2+ Average or normal.
1+ Slightly diminished, low normal.
0 No response.
14. Color, pigmentation, turgor, mobility, moistness, temperature, sensation, presence of lesions.
15.
16. d
17. 1. b
2. c
3. a
4. c
5. b
6. a
7. a
8. b
9. c
10. a
18.
19. S1—mitral and tricuspid areas.
S2—aortic and pulmonic areas.
20. S3—apex of heart and lower left sternal border signifies cardiac decompensation, Ken-tuc-ky.
S4—apex of heart at lower left sternal border signifies cardiac disease, Ten-nes-see.
21. Pulse deficit.
22. b
23. Hyperactive bowel sounds: due to blood in bowel, diarrhea or to partial bowel obstruction (sounds become high-pitched and tinkling or come in “rushes,” followed by silence as obstruction progresses). Hypoactive bowel sounds: absent bowel sounds may be due to complete bowel obstruction or systemic illness. Bowel sounds hypoactive, quiet, and infrequent may be due to paralytic ileus or no obvious cause.
24. a. Quantity.
b. Color.
c. Odor.
d. pH.
e. Specific gravity.
25. a. Presence of lesions.
b. Discharge.
26. a. 3
b. 5
c. 2
d. 6
e. 4
f. 1
27. a. The seventh cranial nerve supplies both motor and sensory function. The eyelid closure is a result of the motor function.
28. c. These sounds are hollow, muffled sounds that are heard over the bronchial area.
29. a. The S2 heart sound represents closure of the aortic and pulmonic valves.
30. d. The tricuspid valve separates the right atrium and ventricle; therefore, it is heard best at the sternal border, fifth intercostal space.
31. d. There is a decreased number and size of the sweat glands. Ciliary action decreases, less ability to retain water, and increased capillary fragility occurs as we age.
32. b. LVN/LPNs can perform focus assessments on clients following the initial assessment by the RN. All changes in the client’s condition must be reported to the RN.
33. Rationale for using Leopold’s maneuvers:
a. Determines fetal position.
b. Locates back, arms, legs, etc., of fetus.
c. Determines presentation of fetus.
d. Determines degree of engagement.
34. Completing an Apgar score.
a. Heart tone is 2.
b. Respiratory effort is 1.
c. Muscle tone is 2.
d. Reflex irritability is 2.
e. Color is 2.
Total overall score is 9.