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During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

Anterior chest

Neck

Heart

Abdomen

Answer and Explanation

The Correct Answer is D

A. In the anterior chest assessment, auscultation usually follows inspection and is typically done before percussion.

B. In the neck assessment, the nurse may inspect and then auscultate (e.g., carotid arteries) before palpation.

C. In the heart assessment, auscultation follows inspection but may not involve percussion.

D. In the abdomen, the correct order is to inspect, auscultate, and then percuss to assess bowel sounds effectively before creating additional disturbances with percussion.

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Correct Answer is D

Explanation

A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.

B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.

C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.

D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.

A. Facial drooping B. Frequent diarrhea C. Steady gait D. Vocal clarity

Correct Answer is A

Explanation

A. Facial drooping is a common symptom following a stroke, particularly if it affects areas of the brain responsible for facial movement.

B. Frequent diarrhea is not typically associated with stroke and may be related to other factors.

C. A steady gait is unlikely following a stroke, especially if the stroke has affected motor control or balance.

D. Vocal clarity can be affected after a stroke, but facial drooping is a more immediate and recognizable alteration in neurologic function.

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During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

Nursing Test Bank

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