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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. This is because Humulin R is a clear and colorless solution that can be given by subcutaneous injection.

A 0.5 mL syringe can hold up to 50 units of insulin, which is enough for the prescribed dose of 7 units. A 30 gauge, 8 mm needle is suitable for thin patients with poor skin turgor. Injecting at a 90-degree angle ensures that the insulin reaches the subcutaneous tissue and not the muscle.

Choice A is wrong because a 31 gauge, 6 mm needle is too short and may not deliver the insulin into the subcutaneous tissue.

Choice C is wrong because pinching the skin is not necessary for thin patients with poor skin turgor.

Choice D is wrong because a 1.0 mL syringe is too large for the prescribed dose of 7 units and may cause dosing errors. A 28 gauge, 12.7 mm needle is too long and may inject the insulin into the muscle, which can affect its absorption and action.

A. Acute Confusion. B. Self-Care Deficit. C. Risk for Impaired Skin Integrity. D. Ineffective Airway Clearance.

Correct Answer is D

Explanation

Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.

Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.

Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.

A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.

Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.

Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.

A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.

Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.

Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.

A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.

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The nurse is preparing to perform a physical assessment. What are the four techniques used?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has diabetes Type I, a body mass index (BMI) of 17 and poor skin turgor. How should the nurse plan to administer the prescribed. Humulin R 7 units subcutaneously?

Correct Answer is B

Explanation

A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6. Which nursing diagnosis is the priority?

Correct Answer is D

Explanation

Following a uterine biopsy, a client asks a nurse, “Do you think I have cancer?” Which response by the nurse would most likely prompt the client to elaborate on their concerns?

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