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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. What is this technique?
- A. Auscultation
- B. Deep palpation
- C. Light palpation
- D. Percussion
Correct Answer: B
Rationale: Deep palpation is used to detect tenderness or masses of the abdomen.
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The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?
- A. 1 second
- B. 2 seconds
- C. 3 seconds
- D. 4 seconds
Correct Answer: C
Rationale: Capillary refill should take fewer than 3 seconds.
The nurse is collecting data during an initial assessment. What can be seen heard measured or felt and is objective?
- A. Symptom
- B. Observation
- C. Sign
- D. Assessment
Correct Answer: C
Rationale: A sign can be seen, heard, measured, or felt.
The nurse is obtaining a history of a patient's present illness. The PQRST system is used for the interview. What does the R stand for in this system?
- A. Random
- B. Region
- C. Result
- D. Recent
Correct Answer: B
Rationale: In the PQRST system, the R stands for region.
Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine?
- A. Sounds for auscultation
- B. Data about physical features
- C. Changes in structural integrity
- D. Density of underlying tissue
Correct Answer: D
Rationale: The sounds indicate the density of the underlying tissue.
As part of an assessment the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?
- A. Assessments
- B. Symptoms
- C. Signs
- D. Observations
Correct Answer: B
Rationale: Symptoms are subjective indications of illness that are perceived by the patient.