The nurse is preparing to perform a physical assessment. What are the four techniques used?
Palpation, relationship, inspection, and evaluation.
Inspection, palpation, percussion, and auscultation.
Vital signs, health history, general survey, and height and weight.
Auscultation, general survey, vital signs, and color.
The Correct Answer is B
Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.
Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.
Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.
Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.
Choice A is wrong because relationship and evaluation are not techniques of physical assessment.
Relationship refers to the rapport and trust established between the nurse and the patient.
Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.
Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.
They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.
Choice D is wrong because color is not a technique of physical assessment.
Color is an aspect of inspection, which is one of the techniques of physical assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because offering fluids that the client likes and in small amounts can help increase the client’s fluid intake and prevent dehydration. According to, some other nursing measures that can help improve the client’s nutritional intake are:
- Encouraging favorite foods from home, when possible.
- Providing frequent oral hygiene.
- Providing a pleasant environment during mealtime.
- Providing assistance with eating, if needed.
Choice A is wrong because placing a freshwater pitcher on the bedside table may not be enough to motivate the client to drink more fluids, especially if the client does not like plain water or has difficulty reaching for the pitcher.
Choice C is wrong because explaining the problems of inadequate intake may not be effective in changing the client’s behavior, and may even cause anxiety or resentment.
Choice D is wrong because stressing the importance of drinking fluids may also be ineffective or counterproductive, as it may sound like nagging or lecturing to the client.
Correct Answer is A
Explanation
This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.
This is a serious condition that requires immediate medical attention.
Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.
It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.
Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.
It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.
Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.
It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.
Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.
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