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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.

B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.

C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.

D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.

A. A child whose parents answer questions for the child. B. A child who has frequent visitors C. A child who uses the call light frequently D. A child who has a BMI indicating obesity

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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The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?

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Correct Answer is A

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