Chapter 16, Nursing Assessment Focused Assessments Answers
Question 1 of 24
In which order would the nurse perform an assessment of the integumentary system.
Review the patient’s medical records for preexisting issues with skin, hair, or nails.
Interview the patient to complete the general survey, health history, and review of systems.
Complete physical examination of the skin, hair, and nails.
The integumentary system assessment begins with review of medical records to identify potential areas of concern. The nurse then interviews the patient before completing the physical examination.
Question 2 of 24
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Which components would the nurse assess during palpation of the skin?
Clubbing
Clubbing is assessed when examining the nails, not the skin.
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Swelling
Swelling should be assessed during the palpation phase of the examination.
Correct
Skin texture
Skin texture should be assessed during the palpation phase of the examination.
Discoloration
Skin discoloration should be assessed during the inspection phase of the examination, not the palpation phase.
Correct
Skin temperature
Skin temperature should be assessed during the palpation phase of the examination.
Question 3 of 24
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When the nurse identifies clubbing of a patient’s nails, which type of medical condition would the nurse suspect as the cause?
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Cardiac
Clubbing is a condition in which there is enlargement of the ends of one or more fingers or toes and is associated with decreased peripheral perfusion due to cardiac or respiratory problems.
Neurologic
Problems in the neurologic system do not cause clubbing of the nails.
Gastrointestinal
Gastrointestinal problems are not associated with nail clubbing.
Musculoskeletal
Musculoskeletal conditions do not cause clubbing of the nails.
Question 4 of 24
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Which part of the eye would the nurse palpate gently to assess for nodules or pain?
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Lens
The lens helps refract light to be focused on the retina and should not be palpated to assess for nodules or pain.
Correct
Eyelid
The eyelids should be gently palpated to feel for nodules and pain.
Cornea
The cornea is the transparent layer forming the front of the eye and should not be palpated to assess for nodules or pain.
Orbital bone
The orbital bone is located on either side of the nose and will not reflect nodules or pain to the eye upon palpation.
Question 5 of 24
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Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness?
Nostrils
Palpation of the nostrils is not part of the physical examination.
Mucosa
Palpation of the mucosa is not part of the physical examination.
Correct
Sinuses
The nurse palpates the sinuses to assess for swelling, drainage, and tenderness during the physical examination of the nose.
Septum
The nasal septum is the bone and cartilage in the nose that separates the nasal cavity into the two nostrils. Palpation for swelling and drainage of the septum is not part of the physical examination.
Question 6 of 24
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When examining the head and its associated structures, which unexpected findings would the nurse document?
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Lumps
The presence of lumps is an unexpected finding that should be documented by the nurse.
Correct
Edema
Edema is an unexpected finding that the nurse would document.
Correct
Lesions
The existence of lesions is an unexpected finding that the nurse would document.
Symmetry
Asymmetry, not symmetry, of the head and its associated structures would be an unexpected finding that the nurse would need to document.
Correct
Discoloration
Discoloration is an unexpected finding that the nurse should document.
Question 7 of 24
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Which techniques would the nurse utilize to auscultate the patient’s chest during the respiratory assessment?
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Listen for a full respiratory cycle.
At each auscultation site, the nurse listens for a full respiratory cycle (inspiration and expiration).
Correct
Use a systematic pattern.
The breath sounds in each of the lobes of the lungs are auscultated using a systematic pattern.
Assess at least two lobes.
Each lobe needs to be assessed for airflow and any unexpected sounds. The right lung has three lobes, and the left lung has two lobes.
Feel for depth of breathing.
The nurse feels for depth of breathing during palpation, not auscultation.
Correct
Listen for unexpected sounds.
The nurse listens to each lobe for airflow and any unexpected sounds.
Question 8 of 24 – Chapter 16, Nursing Assessment Focused Assessments Answers
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Which aspects does the nurse assess while palpating the chest during the respiratory system assessment?
Respiratory rate
The nurse uses inspection, not palpation, to assess the patient’s breathing pattern (rate, rhythm, depth, and effort).
Correct
Masses
The nurse palpates to assess for masses or tenderness.
Correct
Skin moisture
The nurse palpates to assess for skin moisture and temperature.
Front-to-back diameter
The nurse uses inspection, not palpation, to assess the chest for shape as well as the front-to-back diameter.
Breathing effort
The nurse uses inspection, not palpation, to assess breathing effort to ensure that there is no shortness of breath or difficulty breathing.
Question 9 of 24
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Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment?
Lung capacity
Lung capacity is assessed using a spirometer.
Lung shape
This technique does not assess for lung shape. The chest is assessed for symmetry and shape during inspection, not palpation.
Respiratory rate
Respiratory rate is assessed by counting the number of inspirations and expirations.
Correct
Depth of respirations
Depth of respirations is assessed by placing the thumbs on either side of the spine and noting thumb movement.
Question 10 of 24
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Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems?
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Respiratory
The heart and lungs share a common circulatory system, such that a problem affecting the cardiovascular system can also affect the respiratory system.
Genitourinary
The genitourinary system is not generally connected to assessment of the cardiovascular system.
Gastrointestinal
The gastrointestinal system is not generally connected to assessment of the cardiovascular system.
Musculoskeletal
The musculoskeletal system is not generally connected to assessment of the cardiovascular system.
Question 11 of 24
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Which actions would the nurse implement during auscultation of the cardiovascular system?
Listen at all three valves
The nurse auscultates the heart at each of the four valves to determine blood flow through the chambers as well as Erb’s point.
Evaluate for symmetry
The nurse palpates peripheral pulses for symmetry, but heart sounds are not auscultated for symmetry.
Correct
Assess rate and rhythm
The nurse listens for the rate and rhythm of the apical pulse.
Feel for quality of pulses
The nurse palpates the peripheral pulses to determine the pulse rate, rhythm, quality, and symmetry. This does not involve auscultation.
Correct
Use both sides of stethoscope
The nurse uses both sides of the stethoscope to assess for both low- and high-pitched sounds.
Question 12 of 24
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Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities?
Apical pulse
The apical pulse is not located on the lower extremities.
Peripheral pulses
Peripheral pulses are assessed during the palpation phase.
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Peripheral perfusion
The skin and lower extremities are inspected for evidence of peripheral perfusion.
Heart rhythm
Assessment of heart rhythm occurs during palpation and auscultation, not inspection.
Question 13 of 24
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Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview?
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Review of health records
The review of health records provides information on any preexisting musculoskeletal problems. This knowledge assists the nurse in focusing questions during the health history interview and review of systems.
Organization of equipment
Organization of equipment does not facilitate focusing questions during the health history interview.
Analysis of the review of systems
The review of systems occurs after the health history, so it would not help focus questions during the health history interview.
Completion of the physical examination
The physical examination occurs after the health history, so it would not help focus questions during the health history interview.
Question 14 of 24
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Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination?
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Masses
The nurse assesses for masses during the palpation phase of the musculoskeletal examination. Masses are indicative of musculoskeletal problems.
Correct
Crepitus
Crepitus is a crackling or popping sound, and the nurse assesses for this during the palpation phase of a musculoskeletal examination.
Correct
Tenderness
The nurse assesses for tenderness during the palpation phase of the musculoskeletal examination.
Deep tendon reflexes
The nurse assesses deep tendon reflexes with a reflex hammer after the palpation phase.
Postural abnormalities
Postural abnormalities are assessed during the inspection phase, not the palpation phase, of the musculoskeletal examination.
Question 15 of 24
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Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider?
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Pain
Pain is an unexpected finding that should be reported to the health care provider.
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Lesions
Lesions are unexpected findings that the nurse should report to the health care provider.
Absence of crepitus
Crepitus, a popping or crackling sound, is an unexpected finding and should be reported to the health care provider. Absence of crepitus is an expected finding and does not need to be reported.
Correct
Abnormal posture or gait
Abnormal posture or gait is an unexpected finding that should be reported to the health care provider.
Presence of deep tendon reflexes
The absence or diminution of deep tendon reflexes should be reported to the health care provider. The presence of deep tendon reflexes is an expected finding that does not need to be reported.
Question 16 of 24
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Which assessment technique would the nurse use during the neurologic assessment?
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Inspection
The nurse uses the assessment techniques of inspection and palpation during a neurologic examination.
Reflexology
Reflexology is not one of the four recognized assessment techniques used by nurses. It is a specialized massage technique involving pressure points and should not be confused with assessment of reflexes.
Percussion
Percussion is not utilized during a neurologic examination because the examination assesses the motor, autonomic, behavioral, sensory, and cognitive elements of neurologic function.
Auscultation
Auscultation is not utilized during a neurologic examination.
Question 17 of 24
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Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body?
Motor nerve
Motor nerve information is assessed through the performance of various tasks.
Cranial nerve
Cranial nerve assessment involves the eyes, upper nasal passages, pons, and medulla oblongata and does not require dull and sharp stimuli for assessment.
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Sensory nerve
Sensory nerve information is assessed through the use of dull and sharp stimuli to check for normal reactions from such stimuli.
Accessory nerve
The accessory nerve is a cranial nerve that controls certain muscles believed to originate in the brain.
Question 18 of 24
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Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes?
Motor nerve
Motor nerve information is assessed through the performance of various tasks.
Correct
Cranial nerve
Cranial nerve assessment involves the eyes, upper nasal passages, pons, and medulla oblongata. Cranial nerves are assessed through evaluation of eye movements and pupillary reflex.
Sensory nerve
Sensory nerve information is assessed through the use of dull and sharp stimuli to check for normal reactions from such stimuli.
Accessory nerve
The accessory nerve is a cranial nerve that controls certain muscles believed to originate in the brain.
Question 19 of 24
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Which assessment techniques would the nurse use during the abdominal assessment?
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Palpation
The nurse palpates the abdomen in each quadrant, starting with light pressure and then using deeper pressure. The nurse also palpates the bladder area. A palpable, firm bladder suggests that it is distended with urine.
Correct
Inspection
The nurse inspects the abdomen for discoloration, bruising, edema, lesions, stretch marks, and scarring. Bulges, distention, or protruding masses are also noted.
Percussion
Percussion is not used in the abdominal assessment.
Observation
Observation is not considered an assessment technique; nurses do observe during the inspection phase.
Correct
Auscultation
The nurse uses the diaphragm of the stethoscope to auscultate bowel sounds in all four quadrants of the abdomen.
Question 20 of 24 – Chapter 16, Nursing Assessment Focused Assessments Answers
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The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems?
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Urinary
The urinary system is assessed during an evaluation of the abdominal and gastrointestinal organs because it involves intake and elimination and affects the gastrointestinal system.
Correct
Digestive
The digestive system is assessed during an evaluation of the abdominal and gastrointestinal organs because its malfunction will produce further problems in the gastrointestinal system.
Endocrine
The endocrine system is not assessed during an evaluation of the abdominal and gastrointestinal organs because it involves the adrenal, pituitary, and thyroid glands.
Circulatory
The circulatory system is not assessed during an evaluation of the abdominal and gastrointestinal organs because it is part of the cardiovascular system.
Reproductive
The reproductive system is not assessed during an evaluation of the abdominal and gastrointestinal organs; it is assessed during an evaluation of the genitals and reproductive health of the patient.
Question 21 of 24
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Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope?
Wheezes
The nurse assesses for wheezes during the respiratory system assessment.
Blood flow
The nurse uses the bell of the stethoscope to listen for blood flow.
Correct
Bowel sounds
The nurse utilizes the diaphragm of the stethoscope to listen to bowel sounds in all four quadrants of the abdomen.
Breath sounds
The nurse assesses for breath sounds during the respiratory system assessment.
Question 22 of 24
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Which findings would the nurse recognize as abnormal during assessment of the male genitalia?
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Rashes
Rashes can be indicative of contact dermatitis, psoriasis, or genital herpes, and other conditions.
Correct
Lesions
Lesions of the male genitalia can indicate infection.
Correct
Masses
Masses are assessed during the palpation phase of an assessment of the male genitalia.
Dimpling
Nurses assess breast tissue for dimpling.
Correct
Discharge
Discharge is assessed during the inspection phase and may indicate testicular torsion or other genitalia-related problems.
Question 23 of 24
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Which technique would the nurse use to palpate the breast tissue?
Both hands
Using both hands to palpate breast tissue is incorrect technique, as the nurse will not be able to feel smaller masses within the breast.
Palm of one hand
Using the palm of one hand to palpate breast tissue will not allow the nurse to find small masses during the breast examination.
Correct
Two to three fingers
The entire breast tissue should be palpated using two to three fingers.
Thumb and forefinger
Using just the thumb and forefinger to palpate breast tissue is incorrect technique, potentially causing the nurse to overlook important assessment findings.
Question 24 of 24
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During the breast and genital examination, which findings would the nurse document and report to the health care provider?
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Lesions on the genitalia
Lesions, growths, and masses on the genitalia can indicate systemic problems and should be documented and reported.
Correct
Presence of hemorrhoids
The presence of hemorrhoids can cause rectal bleeding, which is an unexpected finding that the nurse should document and report.
Correct
Unusual odor or discharge
Unusual odor or discharge is a sign of infection and should be documented and reported.
Correct
Excoriation of the breast tissue
Rashes, lesions, or excoriation of the breast tissue could be indicative of breast cancer, and the nurse should document and report the findings.
Symmetry of the breast tissue
Extreme asymmetry, not symmetry, of the breast tissue should be documented and reported.
Chapter 16, Nursing Assessment Focused Assessments Answers
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