A nurse is performing a physical assessment on a patient. Which sequence should the nurse follow?

Auscultation, palpation, percussion, inspection

Inspection, percussion, palpation, auscultation

Inspection, palpation, percussion, auscultation

Palpation, inspection, percussion, auscultation

Answer and Explanation

The Correct Answer is C

Reasoning:

The standard physical assessment sequence is designed to ensure data accuracy and minimize clinician-induced artifacts. For most body systems, the order moves from the least invasive to the most invasive technique. This prevents the alteration of physical findings, such as bowel sounds or tenderness, before they can be properly assessed.

A. Starting with auscultation is generally incorrect for a standard head-to-toe assessment. Techniques like palpation and percussion should always be preceded by inspection to gather visual data. The only exception to the standard order is the abdominal assessment, where auscultation follows inspection to avoid altering bowel motility.

B. This sequence is incorrect because palpation and percussion are reversed. Palpation (using touch to feel for surface characteristics) usually precedes percussion (tapping to assess underlying density) in a standard systemic review. Performing percussion before palpation might unnecessarily agitate the tissue or cause discomfort that interferes with palpation.

C. The sequence of inspection, palpation, percussion, and auscultation is the standard for assessing most body systems (excluding the abdomen). Inspection provides visual cues, palpation assesses texture and temperature, percussion determines the density of underlying structures, and auscultation captures internal sounds produced by organs like the heart and lungs.

D. Palpation should never be the first step in an assessment. Starting with palpation can mask subtle visual findings and may cause the patient to guard or tense their muscles, making the rest of the examination difficult. Inspection must always be the first step to establish a baseline.

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Correct Answer is A

Explanation

Reasoning:

The olfactory nerve is the primary sensory pathway responsible for the transduction of odorant molecules into neural impulses. Testing this nerve requires the use of non-irritating, familiar aromatic substances to ensure that the sensory mucosa and the olfactory bulb are functioning without obstruction or neural pathway interruption.

A. The correct action involves having the client close their eyes and identify a specific, non-acrid scent such as coffee or vanilla. This assessment specifically targets the sensory function of the olfactory nerve. Any inability to identify odors, known as anosmia, may indicate localized trauma or neurological deficits.

B. Observing facial symmetry during a smile evaluates the motor branch of the facial nerve, also known as cranial nerve VII. It does not assess the olfactory function. This test is typically used to rule out peripheral facial palsy or central neurological involvement affecting the muscles of facial expression.

C. Assessing the pupillary response to light evaluates the optic nerve for sensory input and the oculomotor nerve for the motor response. These correspond to cranial nerves II and III, respectively. This test is essential for checking the midbrain function and intracranial pressure rather than olfaction.

D. Using a tongue blade to check the gag reflex assesses the glossopharyngeal and vagus nerves, which are cranial nerves IX and X. These nerves are responsible for the sensory and motor components of the pharyngeal reflex. This action is unrelated to the assessment of the olfactory nerve.

A. Palpable lymph nodes B. Symmetrical thyroid gland C. Tracheal deviation from midline D. Visible jugular venous pulsation

Correct Answer is C

Explanation

Reasoning:

The neck contains vital structures, including the trachea, carotid arteries, and thyroid. Assessment findings that suggest a shift in these structures can indicate life-threatening intrathoracic pressure changes. Immediate intervention is required when the airway or hemodynamic stability is compromised by a physical displacement of the midline structures.

A. Small, mobile, non-tender lymph nodes (less than 1 centimeter) can be a normal finding in some adults. While enlarged or tender nodes require further investigation to rule out infection or malignancy, they do not typically represent an acute emergency requiring "immediate" intervention in a stable patient.

B. A symmetrical thyroid gland that is not enlarged is a normal physical assessment finding. It indicates the absence of goiter, nodules, or significant hypertrophy. This finding would be documented as a negative result and certainly does not require any medical or nursing intervention.

C. Tracheal deviation is a late and critical sign of a tension pneumothorax or a large mediastinal mass. In a tension pneumothorax, air trapped in the pleural space shifts the mediastinum toward the unaffected side, compressing the heart and great vessels. This is a medical emergency requiring needle decompression.

D. Visible jugular venous pulsation (JVP) can be a normal finding when a patient is lying flat. While elevated JVP (measured at 45 degrees) can indicate fluid overload or heart failure, it is a clinical sign to be monitored rather than a reason for "immediate" emergency intervention like a deviated trachea.

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A nurse is performing a physical assessment on a patient. Which sequence should the nurse follow?

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