Chapter 27 Physical Assessment

Chapter 27  Physical Assessment

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. When assessing a client, the nurse notes localized redness and hyperthermia. This is most often associated with:
a.
high fever.
c.
infection.
b.
shock.
d.
arteriosclerosis.

ANS: C
Redness indicates inflammation. Hyperthermia or increased body heat also indicates an infection. Localized redness and hyperthermia is not associated with a high fever, shock, or arteriosclerosis.

PTS: 1 DIF: Analysis REF: Table 27-3 Assessment of the Skin

2. When assessing a client’s integumentary status, the nurse notes a 1.0-cm, red, nonpalpable lesion on the client’s arm. This should be recorded as a:
a.
papule.
c.
patch.
b.
nodule.
d.
macule.

ANS: D
A macule is a nonpalpable lesion, described as a localized change only in skin color, 1.0 cm in size. A papule, patch, and nodule are all palpable lesions.

PTS: 1 DIF: Application REF: Table 27-5 Common Skin Lesions

3. To assess the client’s visual acuity, the nurse should use the:
a.
ophthalmoscope.
c.
Snellen chart.
b.
otoscope.
d.
penlight.

ANS: C
Assessment of visual acuity uses the Snellen chart or a chart that contains various-sized letters with standardized numbers at the end of each line of letters. An ophthalmoscope is used by an advanced practice nurse to assess the internal structures of the eyes. An otoscope is used to assess the ear canals. A penlight is used to assess a variety of body structures; however, it is not used to test visual acuity.

PTS: 1 DIF: Application REF: Eyes| Figure 27-5 Snellen Chart

4. During a Weber test, the client reported more sound on the right side. Which of the following does this finding indicate?
a.
Conductive hearing loss in the right ear
b.
Sensorineural hearing loss in the right ear
c.
Conductive hearing loss in the left ear
d.
Sensorineural hearing loss in the right ear

ANS: A
A positive Weber test occurs when sound lateralizes to the affected ear with a unilateral conductive hearing loss. This finding does not indicate conductive hearing loss of the left ear nor sensorineural hearing loss of either ear.

PTS: 1 DIF: Analysis REF: Table 27-11 Assessing Auditory Acuity

5. During auscultation of the chest, the nurse hears soft, breezy, low-pitched sounds that are heard longer on inspiration than expiration. The nurse should record these as:
a.
bronchovesicular sounds.
c.
bronchial sounds.
b.
vesicular sounds.
d.
adventitious sounds.

ANS: B
Vesicular sounds are soft, breezy, and low-pitched sounds that are heard longer on inspiration than expiration. Bronchovesicular sounds are medium-pitched blowing sounds heard equally on inspiration and expiration. Bronchial sounds are loud and high-pitched with a hollow quality heard longer on expiration than inspiration. Adventitious breath sounds are sounds that are superimposed on the normal vesicular, bronchovesicular, and bronchial breath sounds.

PTS: 1 DIF: Application REF: Thorax and Lungs