The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?
Inspection, percussion, palpation, auscultation
Inspection, palpation, percussion, auscultation
Palpation, percussion, inspection, auscultation
Inspection, auscultation, palpation, percussion
The Correct Answer is B
A. Inspection, percussion, palpation, auscultation: This sequence starts with visual inspection, followed by percussion (tapping the body to assess underlying structures), palpation (using the hands to feel for abnormalities), and finally auscultation (listening with a stethoscope to assess sounds such as heart, lung, or bowel sounds). However, palpation is usually performed before percussion.
B. Inspection, palpation, percussion, auscultation: This is the correct sequence for performing a physical examination. It begins with visual inspection, followed by palpation to assess for
tenderness, masses, or other abnormalities, then percussion to evaluate the density of underlying structures, and finally auscultation to listen to internal sounds.
C. Palpation, percussion, inspection, auscultation: This sequence starts with palpation, followed by percussion, then inspection, and finally auscultation. However, inspection is typically performed before palpation in a physical examination.
D. Inspection, auscultation, palpation, percussion: This sequence starts with visual inspection, followed by auscultation, palpation, and percussion. While auscultation often follows inspection, palpation is usually performed before auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "It is best to just ignore this and to not respond to his questions.": Ignoring the child's questions about the death of his grandfather may lead to feelings of confusion or abandonment. It is important to address the child's concerns and provide appropriate support and guidance.
B. "He will eventually figure this out on his own.": While children may gradually come to understand the permanence of death as they mature, it is essential to provide support and explanations to help them cope with grief and loss.
C. "You have to keep repeating that his grandfather is never coming back.": Continually
repeating that the grandfather is never coming back may be distressing for the child and does not provide constructive support or help the child understand the concept of death.
D. "This is normal; children his age do not understand the permanence of death.": This response acknowledges the child's age-appropriate understanding of death and provides reassurance to the mother that her son's reaction is typical. It opens the door for the nurse to offer guidance on how to support the child through the grieving process and gradually help him comprehend the permanence of death.
Correct Answer is A
Explanation
A. A child whose parents answer questions for the child. This behavior may indicate that the child's parents are controlling or dominating, possibly preventing the child from expressing their own thoughts or feelings. It could be a sign of emotional or psychological abuse, where the child's autonomy and voice are suppressed.
B. A child who has frequent visitors: While frequent visitors may raise concerns about the child's social environment, it does not necessarily indicate abuse. Further assessment would be needed to determine the nature of these visits and their impact on the child's well-being.
C. A child who uses the call light frequently: Frequent use of the call light may indicate physical discomfort, illness, or anxiety, but it does not inherently suggest abuse. It could be related to the child's medical condition or emotional state.
D. A child who has a BMI indicating obesity: Obesity alone is not indicative of abuse. While it may raise concerns about the child's health and well-being, it does not directly point to abuse unless there are additional signs or symptoms suggestive of neglect or mistreatment.
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