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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.
B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the
thermometer in their mouth.
C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic
measurements or when rectal measurement is contraindicated.
D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.
However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.
Correct Answer is B
Explanation
A. Epiglottitis
Epiglottitis typically presents with rapid onset of severe sore throat, high fever, difficulty swallowing, and drooling due to inflammation and swelling of the epiglottis. It is a medical emergency requiring immediate intervention but is less likely to present with the described symptoms.
B. Bronchiolitis
Bronchiolitis commonly occurs in infants and young children, often during the winter months. It is characterized by symptoms such as coughing, wheezing, nasal congestion, fever, and
respiratory distress. The described symptoms, including coughing, nasal congestion, and intermittent fever, align with bronchiolitis.
C. Influenza
Influenza typically presents with symptoms such as fever, cough, sore throat, body aches, and fatigue. While coughing and fever are common symptoms of influenza, the presence of apneic spells is less typical of influenza and more indicative of lower respiratory tract infections like bronchiolitis.
D. Croup
Croup is characterized by a barking cough, hoarseness, and respiratory distress often accompanied by stridor. While croup shares some symptoms with bronchiolitis, such as coughing, the absence of stridor in the description suggests bronchiolitis as a more likely diagnosis.
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