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 D

Explanation

A. Increased intracranial pressurE. Pulsation and bulging of the fontanel may be signs of

increased intracranial pressure in infants. However, it is important to differentiate between normal fontanel characteristics and abnormal signs of elevated intracranial pressure. In this case, the pulsation and bulging are likely normal responses to crying and changes in intracranial pressure during the newborn period.

B. Dehydration: Dehydration typically presents with sunken fontanels rather than pulsation and bulging. Dehydration is a serious condition that requires prompt assessment and intervention, but it is not indicated by the findings described in the scenario.

C. Overhydration: Overhydration is not typically associated with pulsation and bulging of the fontanel. Overhydration may lead to fluid overload and edema but does not directly affect fontanel characteristics.

D. These are normal findings: Pulsation and brief bulging of the fontanel in response to crying are considered normal findings in newborns. Fontanels allow for the flexibility of the skull bones during childbirth and provide space for brain growth during infancy. Pulsation and bulging may occur temporarily during crying or changes in intracranial pressure and are not necessarily

indicative of pathology.

A. Place the crushed tablet in the infant's formula. B. Mix the crushed tablet with the infant's cereal. C. Mix the crushed tablet with a small amount of applesauce. D. Crushed tablets should only be mixed with water.

Correct Answer is C

Explanation

A. Place the crushed tablet in the infant's formulA. Mixing crushed tablets with formula may alter the taste or consistency of the formula, making it less palatable for the infant.

B. Mix the crushed tablet with the infant's cereal: Mixing crushed tablets with cereal may also alter the taste and texture of the cereal, potentially making it unappealing to the infant.

C. Mix the crushed tablet with a small amount of applesaucE. Mixing crushed tablets with a small amount of applesauce is a common method for administering medication to infants and

toddlers. The applesauce helps mask the taste and texture of the crushed tablet, making it easier for the child to swallow.

D. Crushed tablets should only be mixed with water: While water can be used to administer crushed tablets, mixing them with water alone may not effectively mask the taste or texture of the medication, making it less likely that the child will swallow it. Mixing with a food like applesauce is often more palatable for young children.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?

Correct Answer is D

Explanation

The nurse is administering a crushed tablet to an 18-month-old infant. What is a recommended guideline for this intervention?

Correct Answer is C

Explanation

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