Question

When performing a physical assessment, which of the following is the first physical assessment technique that should be used?

Answer 1

Correct Answers:

Inspection

Rationale :

👀Inspection is the first technique used because it involves careful visual observation before touching the client.

🩺Starting with inspection allows the nurse to gather baseline physical information without altering body characteristics.

🔍Techniques such as palpation or percussion could change findings like swelling, shape, or symmetry if performed first.

📏Performing inspection first ensures that all visible signs are documented accurately before proceeding with further assessment.

📌Core Message

Begin physical assessment with inspection to establish a visual baseline before using other assessment techniques.

Answer 2

Correct Answers:

To provide information to guide the physical assessment

Rationale :

🧍‍♂️A general survey provides a broad overview of the client's appearance, behavior, and mobility.

📋This initial observation helps the nurse form priorities and direction for the focused physical exam.

🔍General surveys include facial expressions, posture, body movements, and nutritional status.

🛡️It acts as a starting point for identifying abnormal findings that may require more in-depth assessment.

📌Core Message

A general survey gives important observational cues that help shape the nurse’s approach to further physical assessment.

Answer 3

Correct Answers:

Right to refuse
Respect
Privacy
Confidentiality

Rationale :

⚖Clients have the right to refuse any procedure, including assessments.

🤝Respect promotes trust and encourages client cooperation.

🚪Maintaining privacy upholds the dignity and modesty of the client during examination.

🔐Confidentiality ensures that personal and health information is protected at all times.

📌Core Message

During assessment, the nurse must uphold ethical principles such as privacy, respect, consent, and confidentiality to promote trust and safety.

Answer 4

Correct Answers:

Verify the client's identity

Rationale :

💁‍♂️Verifying the client’s identity is essential to ensure the right care is given to the right person.

📛This step helps prevent errors in documentation and communication.

🛑It’s a critical part of patient safety protocols in all health care settings.

🧾Skipping identification could lead to misdiagnosis or incorrect treatment.

📌Core Message

The first step in any health assessment is verifying identity to ensure patient safety and accurate care delivery.

Answer 5

Correct Answers:

Vital signs

Rationale :

🩺Unlicensed assistive personnel (UAP) can perform non-invasive and routine tasks, like measuring vital signs.

📊Tasks that require nursing judgment—such as assessing heart sounds or medical history—cannot be delegated.

📋Vital signs are part of the baseline data collection but require RN interpretation.

🛡️Delegation must always follow the principles of right task, right person, and right circumstances.

📌Core Message

UAPs may be delegated tasks like vital sign collection, but nurses retain responsibility for interpretation and clinical judgment.

Answer 6

Correct Answers:

History of hypertension

Rationale :

👁️The general survey includes observable data such as appearance, posture, mobility, and behavior.

📋A medical diagnosis like hypertension is part of the health history, not the general survey.

🔍The survey focuses on what can be seen or sensed immediately during first contact.

🛡️Differentiating between observed signs and reported history improves assessment accuracy.

📌Core Message

General survey includes observable characteristics, while diagnosed conditions belong in the medical history.

Answer 7

Correct Answers:

Client's age

Rationale :

📆The client’s age is part of demographic information, not past medical history.

🦠Immunizations, illnesses, and hospitalizations are events that occurred in the client's health past.

📋The age is relevant to health status but not categorized as a medical event.

🛡️Accurate classification of history components ensures a complete and organized assessment record.

📌Core Message

The client’s age is considered demographic data, not part of past medical history like illnesses or hospitalizations.

Answer 8

Correct Answers:

Request an interpreter to assist the client.

Rationale :

🗣️Using a professional interpreter ensures clear, accurate, and culturally appropriate communication.

📜Healthcare laws and ethical standards require language access services for non-English speakers.

🚫Using family members violates confidentiality and may introduce errors.

🛡️Professional interpreters help gather a valid health history without compromising client rights.

📌Core Message

Always request a professional interpreter when a language barrier exists to ensure safe, respectful, and accurate assessment.

Answer 9

Correct Answers:

A person who appears unconscious but has a weak pulse and shallow breathing.

Rationale :

🚨This person is showing signs of life-threatening instability and must be assessed first.

🧠Unconsciousness and shallow breathing indicate compromised airway and circulation, which is a priority.

📋According to triage principles, the most critically injured but salvageable client is seen first.

🛡️Quick assessment can prevent respiratory or cardiac arrest in this client.

📌Core Message

In emergencies, prioritize clients with life-threatening but treatable conditions, such as unconsciousness with weak vital signs.

Answer 10

Correct Answers:

When answering their call for assistance

Rationale :

📞A client calling for help in their own room is already identified and does not require a second verification.

📋Verification is crucial before procedures, assessments, or medication administration to prevent errors.

🛑Repeating identity checks during casual interactions isn’t practical unless care is being delivered.

🛡️Correctly timed identification checks uphold both safety and workflow efficiency.

📌Core Message

Verifying a client’s identity is essential before clinical tasks, but not required for routine non-clinical interactions.

1 :
When performing a physical assessment, which of the following is the first physical assessment technique that should be used?

2 :
The nurse enters the room to assess a newly admitted client. Which statement best describes the purpose of a general survey?

3 :
Which of the following should always be followed by the nurse when practicing assessment techniques? Select all that apply.

4 :
What is the first thing a nurse should do when conducting a health assessment on a client?

5 :
Which of the following aspects of the complete physical assessment can be delegated by the nurse to the unlicensed assistive personnel (UAP)?

6 :
Which of the following assessment findings is not a part of the general survey?

7 :
Which of the following is not an example of past medical history?

8 :
A nurse is struggling to complete the health history questionnaire because the client speaks Spanish. Which action should the nurse implement?

9 :
The nurse responds to an emergency call for help in the lobby of the health facility and finds a car in the lobby and several people injured. Which person will the nurse examine first?

10 :
Which of the following situations does not require verifying a person's identity required when they are in the hospital?

1 : When performing a physical assessment, which of the following is the first physical assessment technique that should be used?

2 : The nurse enters the room to assess a newly admitted client. Which statement best describes the purpose of a general survey?

3 : Which of the following should always be followed by the nurse when practicing assessment techniques? Select all that apply.

4 : What is the first thing a nurse should do when conducting a health assessment on a client?

5 : Which of the following aspects of the complete physical assessment can be delegated by the nurse to the unlicensed assistive personnel (UAP)?

6 : Which of the following assessment findings is not a part of the general survey?

7 : Which of the following is not an example of past medical history?

8 : A nurse is struggling to complete the health history questionnaire because the client speaks Spanish. Which action should the nurse implement?

9 : The nurse responds to an emergency call for help in the lobby of the health facility and finds a car in the lobby and several people injured. Which person will the nurse examine first?

10 : Which of the following situations does not require verifying a person's identity required when they are in the hospital?

1 :
When performing a physical assessment, which of the following is the first physical assessment technique that should be used?

2 :
The nurse enters the room to assess a newly admitted client. Which statement best describes the purpose of a general survey?

3 :
Which of the following should always be followed by the nurse when practicing assessment techniques? Select all that apply.

4 :
What is the first thing a nurse should do when conducting a health assessment on a client?

5 :
Which of the following aspects of the complete physical assessment can be delegated by the nurse to the unlicensed assistive personnel (UAP)?

6 :
Which of the following assessment findings is not a part of the general survey?

7 :
Which of the following is not an example of past medical history?

8 :
A nurse is struggling to complete the health history questionnaire because the client speaks Spanish. Which action should the nurse implement?

9 :
The nurse responds to an emergency call for help in the lobby of the health facility and finds a car in the lobby and several people injured. Which person will the nurse examine first?

10 :
Which of the following situations does not require verifying a person's identity required when they are in the hospital?