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. A child who is brought to the emergency room with labored breathing: Labored breathing can indicate a serious respiratory problem that requires immediate assessment and intervention.

Conducting a comprehensive health history is crucial to gather information about the child's medical history, current symptoms, and any potential underlying conditions that could be contributing to the breathing difficulty.

B. A child who is a new client in a pediatric officE. While it is important to obtain a comprehensive health history for new clients in a pediatric office, it may not require immediate attention unless the child presents with acute symptoms or concerns.

C. A child who is a routine client and presents with signs of a sinus infection: While a child presenting with signs of a sinus infection may require a comprehensive health history to guide treatment, it may not necessitate immediate attention unless the symptoms are severe or accompanied by complications.

D. A child whose condition is improving: If a child's condition is improving, conducting a comprehensive health history may not be immediately necessary unless there are lingering concerns or new symptoms that arise during follow-up visits.

A. "Can you stand very still while I feel how warm you are?" B. "I am going to listen to your heart." C. "Can I listen to your lungs?" D. "I am going to take your blood pressure now."

Correct Answer is B

Explanation

A. "Can you stand very still while I feel how warm you are?": Toddlers may have difficulty understanding abstract requests or instructions. Asking a toddler to stand still to feel warmth may not effectively communicate the purpose of the assessment and may lead to confusion or

resistance.

B. "I am going to listen to your heart.": This statement provides clear, simple language that the toddler can understand. It prepares the child for the assessment and helps establish trust and cooperation.

C. "Can I listen to your lungs?": While this statement is appropriate for assessing respiratory sounds, it may not be as clear or specific as stating the intention to listen to the heart. Toddlers may not understand the term "lungs" as readily as "heart."

D. "I am going to take your blood pressure now.": This statement may cause anxiety or fear in the toddler, especially if they are unfamiliar with the procedure. It is important to prepare the child for each aspect of the assessment in a developmentally appropriate manner.

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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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Naxlex Comprehensive Predictor Exams

For which children would the nurse conduct an immediate comprehensive health history?

Correct Answer is A

Explanation

A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

Correct Answer is B

Explanation

The mother of a 4-year-old boy tells the nurse that her son occasionally wets his pants during the day. How should the nurse respond?

Which would be least effective in gaining the cooperation of a toddler during a physical examination?

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The nurse is administering acetaminophen PRN to a 9-year-old child on the pediatric ward of the hospital. Which answers reflect nursing actions that follow the rules of the rights of pediatric medication administration? Select all that apply.

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