Question 1

Collecting Objective Data

Accepted Answer

Data directly observed during interaction with client
Information elicited through physical examination techniques

Question 2

Equipment

Accepted Answer

Always collect necessary equipment and place 
where examination will be performed.
Ensure equipment is working properly.
Common items:

Question 3

Preparing the Physical Setting

Accepted Answer

Comfortable, warm temperature
Warm blanket if room temperature cannot be 
adjusted
Private area free of interruption
Quiet area with adequate lighting
Firm examination table or bed at proper height
Bedside table/tray to hold equipment

Question 4

Question #1 
Is the following statement true or false?
Good overhead lighting is an effective substitute for 
sunlight during an assessment.

Accepted Answer

Answer to Question #1 
False
It is best to use sunlight when available. However, 
good overhead lighting is sufficient. A portable lamp is 
helpful for illuminating the skin and for viewing 
shadows or contours.

Question 5

Preparing Oneself

Accepted Answer

Assess own feelings and anxieties before examining 
client
o Practice technique on “pretend client” with 
experienced instructor or practitioner for 
feedback
Prevent transmission of infectious agents

Question 6

Standard Precautions for All Client Care 
#1

Accepted Answer

Based on risk assessment
Hand hygiene
o Alcohol-based hand sanitizer
o Soap and water
Gloves
o Not a substitute for hand hygiene
o Change gloves as needed

Question 7

Standard Precautions for All Client Care 
#2  Skin and nail care

Accepted Answer

o Prevent dryness from handwashing.
o Don't wear artificial nails or extensions.
o Keep natural nails less than ¼ in long.
o Skin under rings may contain high levels of germs.

Question 8

Question #2
Is the following statement true or false?
There are times when gloves must be changed 
between procedures on the same client.

Accepted Answer

Answer to Question #2 
True
Gloves must be changed between tasks and 
procedures on the same client after contact with 
material that may contain a high concentration of 
microorganisms.

Question 9

Approaching and Preparing the Client #3

Accepted Answer

Begin exam with less invasive 1st.
Explain procedure being done.
Integrate health teaching and promotion during exam.
Approach client from right-hand side.
Explain to client why position changes are 
needed
Assist client to change position prn

Question 10

Approaching and Preparing the Client #2

Accepted Answer

Begin exam with less intrusive procedures.
Explain procedure performed.
Integrate health teaching/ promotion during examination.
Approach client from right-hand side.
Explain why position changes needed
Assist to change position as needed.

Question 11

Standard Precautions for All Client Care  Respiratory hygiene/cough etiquette

Accepted Answer

o Use tissues/properly dispose of them.
o Perform hand hygiene.
o Facilities provide needed items for staff, clients, 
and visitors

Question 12

Preparing Oneself
Prevent transmission of infectious agents

Accepted Answer

o Proper hand hygiene
o Wear gloves when necessary
o Properly discard pins or other sharp objects, 
single-client use only
o Wear PPEs when necessary

Question 13

Equipment
Common items:

Accepted Answer

o Gloves and gowns, sphygmomanometer, 
stethoscope, thermometer, watch with second 
hand, penlight, ophthalmoscope, otoscope, 
rulers or flexible tape measures, Doppler 
ultrasound, tongue depressors, cotton balls or 
gauze pads, tuning forks

Question 14

Collecting Objective Data
Nurse must have basic knowledge in 3 areas:

Accepted Answer

o Type & operation of equipment needs
o Preparing self & client for physical examination
o Properly perform techniques: inspection, palpation, percussion, auscultation

Question 15

Approaching and Preparing the Client #1

Accepted Answer

 Establish nurse–client relationship.
 Explain the procedure and physical assessment, describing the 
steps of the examination.
 Respect client’s requests and desires.
 Explain the importance of the examination.

Question 16

Approaching and Preparing the Client #2

Accepted Answer

 If urine specimen needed, explain why; not needed, suggest 
client empty bladder to promote easier examination of the 
abdomen & genital area.
 Leave room while client changes clothes, allow client to leave 
underwear on until genital examination.

Question 17

Examining Older Adults

Accepted Answer

Some positions may be very difficult or impossible 
for older client.
Allow rest periods for older adult, if needed.
Some older adults process information at slower 
rate, explain procedure and integrate teaching in 
clear and slow manner.

Question 18

Question #3 
Is the following statement true or false?
Sitting upright on the side of the examination table is 
a useful position while examining the client as it 
allows full expansion of the lungs.

Accepted Answer

True
Sit up on side of the exam-table/ edge of a chair/ bed 
position for:
evaluate the head, neck, lungs, chest, back, 
breasts, axillae, heart, vital signs, & upper 
extremities. expansion of lungs allowing examiner to assess symmetry of up body.

Question 19

Physical Examination Techniques #1

Accepted Answer

Must master all four techniques
Incorrect performance can result in incorrect 
objective data collection, leading to poor clinical 
judgment, which may adversely affect safe client 
care.
Important questions

Question 20

Physical Examination Techniques #2

Accepted Answer

Important questions
o Did I inspect, palpate, percuss, or auscultate any 
deviations from the normal findings?
o Is the deviation a normal physical, gerontologic, 
or cultural finding or abnormal finding?

Question 21

Physical Examination Techniques #3
Important questions—(for nurse to ask self)

Accepted Answer

o Is more questions to validate/ obtain more information bout my findings?
o Do I need to perform physical assessments on related body systems? 
o Should I validate my findings with instructor/ HCP?
o Should I refer the client & data findings to a pcp?

Question 22

Physical Examination: Inspection

Accepted Answer

Use vision, smell, & hearing
Room at comfort temp
Good lighting
observe before touching
expose part being examined/ draping, rest of client as approp.  
Note characteristics 
Compare symmetry body parts/both sides of any individual body part

Question 23

Physical Examination: Palpation #1

Accepted Answer

 Palpation: hand touch & feel for characteristics:
o Texture (rough/smooth)
o Temp (warm/cold)
o Moisture (dry/wet)
o Mobility (fixed/movable/still/vibrating)
o Consistency (soft/hard/fluid filled)
o Strength pulses (strong/weak/thready/bounding)

Question 24

Physical Examination: Palpation #2

Accepted Answer

Palpation consists of using parts of the hand to 
touch and feel for the following characteristics—
(cont.)
o Size (small/medium/large)
o Shape (well defined/irregular)
o Degree of tenderness

Question 25

Fingerpads

Accepted Answer

Fine discriminations: pulses, 
texture, size, consistency, shape, 
crepitus

Question 26

Ulnar or palmar surface

Accepted Answer

Vibrations, shrills, fremitus

Question 27

Dorsal surface

Accepted Answer

Temperature

Question 28

Question #4
Depressing the skin surface with the dominant hand 
and using a circular motion to palpate falls under 
which palpation type?
A. Moderate palpation
B. Deep palpation
C. Bimanual palpation
D. Light palpation

Accepted Answer

Answer to Question #4 
A. Moderate palpation
Moderate palpation involves depressing the skin 
surface 1 to 2 cm with the dominant hand and using a 
circular motion to feel for easily palpable body organs 
and masses.

Question 29

Physical Examination: Percussion #1

Accepted Answer

Physical Examination: Percussion #1 
 Assessment uses 
o Eliciting pain
o Determining location, size, and shape
o Determining density
o Detecting abnormal masses
o Eliciting reflexes
 Types 
o Direct
o Blunt
o Indirect or mediate

Question 30

Physical Examination: Types of Palpation #1

Accepted Answer

 Types: light, moderate, deep, bimanual

Question 31

Physical Examination: Percussion #2

Accepted Answer

Sounds elicited by percussion
o Resonance
o Hyperresonance
o Tympany
o Dullness
o Flatness

Question 32

Physical Examination: Percussion #2
Sounds elicited by percussion
o Resonance
o Hyperresonance
o Tympany
o Dullness
o Flatness

Accepted Answer

Answer to Question #5 
False
Blunt percussion is used to detect tenderness over 
organs by placing one hand flat on the body surface 
and using the fist of the other hand to strike the back 
of the hand flat on the body surface.

Question 33

Physical Examination: Auscultation #1
 Requires use of stethoscope

Accepted Answer

 Sound classifed:
o Intensity (loud /soft)
o Pitch (high /low)
o Duration (length)
o Quality (musical, cracking, raspy)
 Eliminate distracting /competing noise
 Expose body part being auscultated
 diaphragm= high-pitched; bell= low-pitched

Question 34

Physical Examination: Auscultation #2

Accepted Answer

Physical Examination: Auscultation #2
Place earpieces into 
outer ear canal
 Angle binaurals down toward 
nose
 Hold diaphragm firmly against 
body
 Hold bell lightly against body

Question 35

Correct Use of a Stethoscope

Accepted Answer

Warm diaphragm and bell before use
Explain what you are listening to and answer any 
questions.
Do not apply too much pressure when using the bell 
as it will cause the bell to work like the diaphragm.
Avoid listening through clothes.

Question 36

Question #6
Is the following statement true or false?
When using the stethoscope to auscultate the lungs, 
the nurse should always apply pressure against the 
body when using the bell.

Accepted Answer

Answer:
False
The bell of the stethoscope is used to listen to low-
pitched sounds and should be held lightly against the 
body. If too much pressure is applied, the bell will 
work like the diaphragm and the low-pitched sounds 
may not be detected.

Health Assessment

Chapter 3

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