1. A 58-year-old male patient presents with a two-day history of sharp,
intermittent left lower quadrant abdominal pain. His vital signs are as
follows: BP 150/90 mmHg, HR 88 bpm, RR 16 breaths/min, Temp
37.8°C. Which of the following should the nurse prioritize in the physical
assessment?
A. Auscultation of the heart
B. Palpation of the abdomen
C. Percussion of the thorax
D. Inspection of the extremities
Answer: B. Palpation of the abdomen
Rationale: The patient's symptoms suggest a possible abdominal issue,
which makes abdominal palpation a priority to assess for tenderness,
masses, or other abnormalities.
2. During a comprehensive health assessment, a nurse notes that a patient
has an irregular pulse. The nurse should:
A. Document the finding and proceed with the assessment.
B. Reassess the pulse for a full minute and record the findings.
C. Immediately notify the physician.
D. Skip the assessment of the pulse and move to blood pressure
measurement.
Answer: B. Reassess the pulse for a full minute and record the findings.
Rationale: An irregular pulse may indicate an arrhythmia, and it is
important to reassess and document the findings accurately for further
evaluation.
3. A nurse is assessing the skin of a patient who complains of pruritus.
Which assessment technique is most appropriate?
A. Inspection followed by auscultation
B. Palpation followed by inspection
C. Percussion followed by palpation
D. Auscultation only
Answer: B. Palpation followed by inspection
Rationale: Palpation can help determine the presence of lumps,
moisture, or changes in skin temperature, which should be followed by
inspection for visual signs of skin conditions.
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