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PHYSICAL ASSESSMENT FINAL PRACTICE
SOLUTION 2026 SOLVED ITEMS CONFIRMED
A+
โ is an increased inward curving of the lumbar spine (just above the buttocks). Answer: lordosis โ is the outward curve of the thoracic spine at rib-level Answer: kyphosis โ While auscultating heart sounds, the nurse hears a murmur What should be used to assess it? Answer: The bell of the stethoscope โ The nurse is testing a pt's visual accommodation, which refers to: Answer: Pupillary constriction when looking at a near object โ In using the ophthalmoscope to assess a pt's eyes the nurse notes a red glow in the pupils. What does the nurse do? Answer: Consider it a normal reflection of the light off the inner retina โ Preparing to do an otoscope exam on a 2 yr old. What is correct procedure? Answer: Pull pinna down
โ When using otoscope to assess the nasal cavity, what does the nurse need to do? Answer: Avoid touching the nasal septum w/ the speculum โ During assessment of a 20 yr old pt w/ 3-day history of N/V, nurse notes dry mucosa, deep fissures on tongue. Reflective of: Answer: Dehydration โ When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: Answer: Aortic & pulmonic โ Assessment of 70 yr old - swelling in ankles, jugular venous pulsations. This indicates? Answer: Increased pressure in the right side of his heart โ During assessment of healthy adult, where would you palpate the apical pulse? Answer: Fifth left intercostal space MCL โ While counting apical pulse on 16 yr old, nurse notes irregular rhythm - speeds up on inspiration, slows on exhalation - What is the nurse's response? Answer: NO response - normal!
โ Severe HA in frontotemporal area, throbbing & somewhat relieved when lying down. Mother also had these HA's. What type? Answer: Migraine โ Hyperthyroidism - thyroxine & T3 levels are elevated, what finding would be likely on examination? Answer: Tachycardia โ What is a bruit? Answer: Soft, whooshing, pulsatile sound best heard w/ bell of stethoscope โ What is a characteristic of culture? Answer: Adapts to specific environmental factors & available natural resources โ Describe culturally competent care: Answer: The caregiver understands & attends to the total contxt of the pts situation โ 15 mo old son - mother at a loss for answers about behavior & appetite. What does the nurse do? Answer: Determine whether she is primary caregiver for her son โ If an American Indian comes to the clinic for care the nurse can expect that: Answer: She may also be seeking assistance of shaman or medicine man
โ After completing initial assessmt nurse charts resp are eupnic & pulse is 58. This type of data would be: Answer: objective โ Pt tells nurse he is very nervous and that he "feels hot". This type of data would be: Answer: Subjective โ An example of objective info obtained during the phx assessmt would be: Answer: hx of allergy, use of meds, LMP, scar 2X5cm scar on rt lower forearm โ Which technique uses sense of touch? Palpation, inspection, percussion, auscultation? Answer: Palpation โ What does an otoscope do? Answer: Directs light into the ear canal & onto the tympanic membrane โ What is an important fact about the epidermis? Answer: Replaced every 4 weeks โ What is an important fact about the dermis? Answer: Contains sensory receptors โ Pt says "I sweat a lot but it doesn't have odor." This could be related to: Answer: Eccrine glands
โ Trachea bifurcates anteriorly at the: Answer: Sternal angle โ The primary muscles of respiration are the: Answer: Diaphragm and intercostals โ The most important technique when auscultating on the thorax is: Answer: Side-to side comparison โ When auscultating the chest in an adult, the nurse would: Answer: Use the diaphragm of the stethoscope held firmly against the chest โ Percussion over an area of atelectsis in the lungs would reveal: Answer: Dullness โ A normal finding when assessing the resp system of elderly adult is decreased: Answer: mobility of the thorax โ When inspecting the anterior chest of an adult, the nurse should assess for: Answer: The shape & configuration of the chest wall โ Unequal chest expansion occurs when: Answer: Part of the lung is obstructed or collapsed
โ Pt has long hx of COPD. During assessmt nurse most likely observes: Answer: An anteroposterior-to-transverse diameter ratio of 1: โ During auscultation of breath sounds, the nurse will use the stethoscope correctly as follows: Answer: Listen to at least one full resp in each location โ Nurse suspects injured spleen. What is true regarding assessment of spleen in this situation? Answer: An enlarged spleen should not be palpated because it can rupture easily โ Abdominal pulsations between the xiphoid & umbilicus are: Answer: Normal abdominal aortic pulsations โ The main reason auscultation precedes percussion & palpation of the abdomen is to: Answer: Prevent distortion of bowel sounds that might occur after percussion & palpation โ What is true of bowel sounds? Answer: They are usually high- pitched, gurgling, irregular sounds โ Tenderness along the costovertebral angles is most often indicative of: Answer: Kidney inflammation
โ How would you best describe tasks of late adulthood? Answer: Older adults must accept that they cannot change the past & make peace w/ their lives โ 24 month old - mother describes as a child who falls apart if she changes even the smallest thing in his environment. This behavior: Answer: Can be expected from a toddler. They typically experience ritualism & global thinking โ What is an appropriate health & safety issue to teach the parent of an 8 month old? Answer: Stair guards or gates are important to use at this stage โ 75 yr old man, during the mental status portion of the exam the nurse can expect: Answer: He may take a little longer to respond, but his general knowledge & abilities should not have declined โ What is the first thing to be assessed with aging adults before making judgements about mental status? Answer: Their sensory- perceptive abilities โ Pt admitted to unit after MVA, during mental exam pts speech is dysarthric & she is lethargic. Best approach to this exam? Answer: Plan to defer the rest of the mental status exam
โ Pt in ICU x 10 days. Just been moved to med-surg. During tests of cognitive function the nurse would expect that he: Answer: Will be oriented to place & person but may not be certain of the date โ When evaluating a pt's pain, the nurse knows example of acute pain would be: Answer: kidney stones, low back pain โ 4 year old points to stomach and says "it hurts so bad". Which pain assessment tool would be the best choice? Answer: Wong- Baker Scale (Faces) โ What is the most reliable indicator of pain? Answer: The subjective report โ When assessing the quality of pt's pain the nurse should ask which question? Answer: What does your pain feel like? โ What is true regarding the internal structures of the breast? (What is it composed of?) Answer: Composed of fibrous, glandular, and adipose tissue โ 9 yr old girl says "Am I normal? I don't need a bra yet but my friends do." What is the nurse's best response? Answer: I understand it is hard to feel different from your friends, breasts usually develop btw 8-10 yrs old
โ Pt states she noticed a lump in her left breast near the axilla. The nurse should plan to: Answer: Palpate the unaffected breast first โ What is the purpose of a functional assessment? Answer: With the elderly, it helps to determine how they are managing day-to-day activities โ Nurse suspects pt may be deficient in iron. What lab studies should be anticipated? Answer: Hemoglobin and hematocrit โ To assess the dorsalis pedis artery the nurse would palpate: Answer: Lateral to the extensor tendon of the great toe โ The documentation of a pt pulse states: radial pulses "2+". This indicates what type of pulse? Answer: Normal โ Positive phalen test and tinel sign is Answer: carpel tunnel syndrome โ swelling in supra patellar pouch Answer: bulge sign โ pronation and supination of hand and forearm articulate Answer: radius and ulna
โ lift & abduct flexed knee while palpating greater trochanter with fingers is what type of test? Answer: ortani maneuvar โ injury to brocas area would cause difficulty.... Answer: difficulty speaking โ coin in hand identification would be... Answer: stereognosis โ absent tendon reflex, next we do what? Answer: reinforcement โ cerebellar function tests Answer: coordination โ stroke lateral sole of foot from heel across ball of foot Answer: babinski reflex testing โ eye opening motor response to stimuli verbal response Answer: glasglow coma scale โ baby raises head& arches back like a swan dive Answer: landau reflex of infant
โ breath sounds that are moderate in pitch, inspiration being equal to expiration would be..... Answer: bronchovesicular sounds โ congenital displacement of the urethral meatus to the inferior surface of the penis is... Answer: hypospadias โ which symptoms suggest benign prostatic hypertrophy? Answer: difficulty initiating urination and weak strem โ hepatomegaly is... Answer: enlarged liver โ LUQ contains Answer: spleen โ tenderness during abdomen palpation is expected when palpating the... Answer: sigmoid colon โ positive blumberg sign indicates Answer: peritoneal inflammation โ positive murphys sign is best described as Answer: pain felt when taking a deep breath when examiners fingers are on the approximate location of inflammed gallbladder
โ a young woman has come for her first obgyn exam. because she has not had any children... the examiner expects the cervical os to appear Answer: smooth and circular โ Your patient is to receive 0.9% saline at rate of 75mL/hr. you know this route of administration is..... Answer: parenteral โ the _____ refers to the area at the sternomastoid muscle. this region drains into the abdominal region Answer: supraclaviculaar โ the _________ are the openings between upper and lower eyelids Answer: palpable fissure โ ABCDE stands for.... Answer: ASYMMETRY BOARDER COLOR DIAMETER ELEVATION โ fluid visible behind the tympanic membrane indicates Answer: otitis media โ most common sensorineural hearing loss cause by natural aging Answer: presbycusis
โ pt describes burning, painful sensation that moves around the toes and bottoms of his feet, these symptoms suggest... Answer: neuropathic pain โ nurse is caring for someone who has eczema, the nurse observes that the pt's hair is dull, dry, and sparse. what nutrient should be increased in this pt's diet? Answer: linoleic acid โ deficiency of human growth hormone (hgh) Answer: hypopituitary dwarfism โ hypersecretion of HGH Answer: giantism โ psychological weight disorder Answer: anorexia nervosa โ heredity connective tissue disorder Answer: marfans syndrome โ hypersecretion of HGH in adulthood Answer: acromegaly โ waist to hip ratio greater than 1 in males is .... < 1 in males indicates.... Answer: Android obesity Gynoid obesity
โ which phase of nociception does the opioid drug block the signal of pain? Answer: transmission โ during an exam, pt complains of dull pain in LUQ of abdomen.... is diaphoretic & pale.... what type of pain is this? Answer: visceral โ how would you assess pain for an individual w/ dementia? Answer: PAINAD scale, look for pacing, repetitive yelling โ normal age related finding in the lower extremities of an 80 y/o woman would be..... Answer: diminished strength bilaterally โ pain issues should be anticipated in a cognitively impaired older adult with a hx of? Answer: peripheral vascular disease โ pain in the aging adult is considered to be: Answer: unrelated to the aging process โ which patients will receive anti-depressants for therapy for pain management? Answer: fibromyalgia...trigeminal neuralgia....diabetic neuropathy โ antidepressants are used in pain management of what kind of pain? Answer: chronic
