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Bates’ Guide to Physical Examination and
History Taking 13th Edition Bickley Test
Bank & Rationales
CHAPTER 1 Foundations for Clinical Proficiency MULTIPLE CHOICE
- After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a . Objective. b . Reflective. c . Subjective. d . Introspective. ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a . Objective. b . Reflective. c . Subjective.
d . Introspective. ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used
- The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a . Intuition. b . A set of rules. c . Articles in journals. d . Advice from supervisors. ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: General
- Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a . Intuition. b . The nursing process. c . Clinical knowledge. d . Diagnostic reasoning. ANS: A Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: General
- The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
a . EBP relies on tradition for support of best practices. b . EBP is simply the use of best practice techniques for the treatment of patients. c . EBP emphasizes the use of best evidence with the clinicians experience. d . The patients own preferences are not important with EBP. ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. DIF: Cognitive Level: Applying (Application) REF: p. 5 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a . Patient with postoperative pain b . Newly diagnosed patient with diabetes who needs diabetic teaching c . Individual with a small laceration on the sole of the foot d . Individual with shortness of breath and respiratory distress ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
c Admission . d Collaborative . ANS: A An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nursing process is a sequential method of problem solving that nurses use and includes which steps? a Assessment, treatment, planning, evaluation, discharge, and follow-up . b Admission, assessment, diagnosis, treatment, and discharge planning . c Admission, diagnosis, treatment, evaluation, and discharge planning . d Assessment, diagnosis, outcome identification, planning, implementation, and . evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a . Breathing, pain, and sleep b . Breathing, sleep, and pain c . Sleep, breathing, and pain
d Sleep, pain, and breathing . ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- Which of these would be formulated by a nurse using diagnostic reasoning? a . Nursing diagnosis b . Medical diagnosis c . Diagnostic hypothesis d . Diagnostic assessment ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: General
- Barriers to incorporating EBP include: a . Nurses lack of research skills in evaluating the quality of research studies. b . Lack of significant research studies. c . Insufficient clinical skills of nurses. d . Inadequate physical assessment skills. ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a . Disease originates from the external environment. b . The individual human is a closed system. c . Nurses are responsible for a patients health state. d . Holistic health views the mind, body, and spirit as interdependent. ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse recognizes that the concept of prevention in describing health is essential because: a . Disease can be prevented by treating the external environment. b . The majority of deaths among Americans under age 65 years are not preventable. c . Prevention places the emphasis on the link between health and personal behavior. d . The means to prevention is through treatment provided by primary health care practitioners. ANS: C A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7 MSC: Client Needs: General
- The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
a . Patients history of allergies. b . Patients use of medications at home. c . Last menstrual period 1 month ago. d . 2 5 cm scar on the right lower forearm. ANS: D Objective data are the patients record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. DIF: Cognitive Level: Applying (Application) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a . A follow-up data base to evaluate changes at appropriate intervals b . An episodic data base because of the continuing, complex medical problems of this patient c . A complete health data base because of the nurses primary responsibility for monitoring the patients health d . An emergency data base because of the need to collect information and make accurate diagnoses rapidly ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the persons health care. DIF: Cognitive Level: Applying (Application) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- Which situation is most appropriate during which the nurse performs a focused or problem- centered history?
b . Simultaneously ask history questions while performing the examination and initiating life-saving measures. c . Collect all information on the history form, including social support patterns, strengths, and coping patterns. d . Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit. ANS: B The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A 42 - year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a Identify the cause of his illness. . b Make accurate disease diagnoses. . c Provide cultural health rights for the individual. . d Provide culturally sensitive and appropriate care. . ANS: D The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care. CHAPTER 2 Evaluating Clinical Evidence MULTIPLE CHOICE
- When performing a physical assessment, the first technique the nurse will always use is: a . Palpation. b . Inspection. c . Percussion.
d Auscultation. . ANS: B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a . Usually yields little information. b . Takes time and reveals a surprising amount of information. c . May be somewhat uncomfortable for the expert practitioner. d . Requires a quick glance at the patients body systems before proceeding with palpation. ANS: B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a quick glance. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a . Fingertips; they are more sensitive to small changes in temperature. b . Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c . Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
ANS: D
Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first. DIF: Cognitive Level: Applying (Application) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse would use bimanual palpation technique in which situation? a . Palpating the thorax of an infant b . Palpating the kidneys and uterus c . Assessing pulsations and vibrations d . Assessing the presence of tenderness and pain ANS: B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation. DIF: Cognitive Level: Applying (Application) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a Turgor . b Texture . c Density . d Consistency . ANS: C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a Percussing once over each area . b Quickly lifting the striking finger after each stroke . c Striking with the fingertip, not the finger pad . d Using the wrist to make the strikes, not the arm . ANS: A For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. DIF: Cognitive Level: Applying (Application) REF: p. 116 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a Consider this a normal finding. . b Palpate this area for an underlying mass. . c Reposition the hands, and attempt to percuss in this area again. . d Consider this finding as abnormal, and refer the patient for additional treatment. . ANS: A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
b . Bilaterally percuss the thorax, noting any differences in percussion tones. c . Call for a chest x-ray study, and wait for the results before beginning an assessment. d . Inspect the thorax for any new masses and bleeding associated with respirations. ANS: B Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patients physical status. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a Slope of the earpieces should point posteriorly (toward the occiput). . b Although the stethoscope does not magnify sound, it does block out extraneous . room noise. c Fit and quality of the stethoscope are not as important as its ability to magnify . sound. d Ideal tubing length should be 22 inches to dampen the distortion of sound. . ANS: B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiners nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 116 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a Is used to listen for high-pitched sounds. . b Is used to listen for low-pitched sounds. .
c Should be lightly held against the persons skin to block out low-pitched sounds. . d Should be lightly held against the persons skin to listen for extra heart sounds
. and murmurs. ANS: A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held against the persons skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a Warm the endpiece of the stethoscope by placing it in warm water. . b Leave the gown on the patient to ensure that he or she does not get chilled . during the examination. c Ensure that the bell side of the stethoscope is turned to the on position. . d Check the temperature of the room, and offer blankets to the patient if he or she . feels cold. ANS: D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiners hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. DIF: Cognitive Level: Applying (Application) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a Palpation . b Inspection .
