Question 1

When assessing using mediated percussion,which finger of which hand will the nurse use on the patient's body?&#10;A) Middle finger of dominant hand&#10;B) Index finger of dominant hand&#10;C) Middle finger of nondominant hand&#10;D) Index finger of nondominant hand

Accepted Answer

The middle finger of the nondominant hand is typically used for mediated percussion. This allows for better control and accuracy in the percussion technique.

Question 2

A patient reports that she has periodic fainting spells.In gathering more specific information,the nurse asks where these episodes most commonly occur.In what area is the nurse pursuing symptom investigation?

A) Setting
B) Frequency
C) Chronology
D) Associated manifestations

Setting

Accepted Answer

The nurse is investigating the setting in which the fainting spells occur in order to gather more specific information about the symptoms.

Question 3

Following knee surgery,the patient has an elastic bandage applied to the surgical site.What examination technique is used to assess the patient's distal extremity pulses and temperature?&#10;A) Palpation&#10;B) Inspection&#10;C) Percussion&#10;D) Auscultation

Accepted Answer

Palpation involves using the hands and fingers to touch and feel for various characteristics, such as pulses and temperature. Therefore, palpation would be the appropriate examination technique to assess the patient's distal extremity pulses and temperature. Inspection involves using the eyes to look for abnormalities, percussion involves tapping on a certain area to assess for sound and density, and auscultation involves listening with a stethoscope.

Question 4

Which functional health pattern is the nurse assessing when asking a patient how his or her family feels about the patient being hospitalized?&#10;A) Cognitive-perceptual&#10;B) Role-relationship&#10;C) Coping-stress tolerance&#10;D) Self-perception-self-concept

Accepted Answer

The nurse is assessing the role-relationship functional health pattern, which includes questions about the patient's family and social relationships and how they are affected by the patient's health status, such as being hospitalized.

Question 5

Which of the following findings is a positive sign in relation to a patient with an enlarged liver?&#10;A) Blood pressure of 128/78 mm Hg&#10;B) Pulse of 82 beats per minute&#10;C) Yellow-tinged sclera&#10;D) Painful and swollen great right toe

Accepted Answer

Yellow-tinged sclera indicates jaundice, which can be associated with liver dysfunction, making it a relevant finding in the context of an enlarged liver.

Question 6

As the nurse assesses the patient's neck,the patient tells the nurse that it is so stiff she can hardly move it.The nurse should next perform a(n)_____ examination.&#10;A) emergency&#10;B) screening&#10;C) focused&#10;D) extensive

Accepted Answer

Based on the information provided, the nurse should perform a focused examination specifically targeting the patient's neck to further assess the nature and severity of the stiffness. Emergency examination would be required if the patient is in immediate danger, which is not mentioned in the scenario. A screening examination is usually done to identify risk factors, but the patient has already reported a specific symptom. An extensive examination is not necessary at this point, as the focus is on the neck stiffness.

Question 7

Which part of the stethoscope is best to use when the nurse is listening to low-pitched sounds?&#10;A) Bell&#10;B) Tube&#10;C) Diaphragm&#10;D) The largest area for auscultation

Accepted Answer

The bell is best for listening to low-pitched sounds, such as heart murmurs or bruits, as it has a smaller surface area and can pick up on subtle vibrations.

Question 8

When the nurse is gathering information of a personal nature,which best demonstrates an acceptance of the patient's behaviour?&#10;A) &#34;Tell me,do you drink alcohol like I do?&#34;&#10;B) &#34;Many drugs used for hypertension cause sexual dysfunction.How is your sexual functioning?&#34;&#10;C) &#34;Most of my friends have been divorced.Would you like to tell me about the problems with your divorce?&#34;&#10;D) &#34;Many older people have limited financial resources for food and medications.Is this a concern for you?&#34;

Accepted Answer

Option D shows an acceptance of the patient's possible financial concerns without making any assumptions or judgments about their behavior. Option A is inappropriate as it implies that the nurse drinks alcohol, which may not be professional. Option B may be relevant, but it may be uncomfortable for the patient to discuss their sexual function. Option C is inappropriate as it brings up the nurse's personal life and may be perceived as unprofessional.

Question 9

What does a negative finding obtained from the patient during the initial nursing history indicate?&#10;A) The patient is healthy.&#10;B) The symptom related to the specific health problem presented is delayed.&#10;C) The patient uses health promotion practices.&#10;D) A symptom normally associated with the patient's health problem is absent.

Accepted Answer

A negative finding obtained from the patient during the initial nursing history indicates that a symptom normally associated with the patient's health problem is absent. This may require further assessment to confirm the absence of a symptom or evaluate if there are other underlying health issues that may be contributing to the negative finding. It does not necessarily mean that the patient is healthy or practices good health promotion habits. It may also mean that the symptom related to the specific health problem presented is delayed and may appear later during the course of treatment.

Question 10

Which assessment technique would the nurse have used to document a finding of crepitus?&#10;A) Inspection&#10;B) Palpation&#10;C) Auscultation&#10;D) Percussion

Accepted Answer

Crepitus is a tactile finding detected by palpation, which involves using the hands or fingers to feel the texture, size, and consistency of body structures or movements. Inspection involves visually observing and noting aspects such as color, shape, and symmetry of the body parts. Auscultation involves listening to sounds produced by internal organs such as heart, lungs, and abdomen using a stethoscope. Percussion involves tapping the body with fingers or a percussion hammer to elicit sound and assess underlying tissues or organs.

Question 11

A patient is admitted to the orthopedic unit with a fractured right elbow following a skiing accident.During the initial nursing assessment,what information is related to the functional health pattern regarding the patient's fractured elbow and the treatment he has received?

A) Activity-exercise
B) Cognitive-perceptual
C) Self-perception-self-concept
D) Health perception-health management

Accepted Answer

The answer of A patient is admitted to the orthopedic...

Question 12

While the nurse is taking a health history,the patient indicates that his father and grandfather both had heart attacks and were unable to be very active afterward.Which functional health pattern is reflected in this statement?

A) Health perception-health management
B) Coping-stress tolerance
C) Cognitive-perceptual
D) Activity-exercise

Accepted Answer

The answer of While the nurse is taking a health...

Question 13

The nurse records the following general survey of a patient: "The patient is a 68-year-old male Asian attended by his wife and two daughters.Alert and oriented.Does not make eye contact with the nurse and responds slowly,but appropriately,to questions.No apparent disabilities or distinguishing features." What additional information should be added to this general survey?

A) Body movements
B) Intake and output
C) Reasons for contact with the health care system
D) Comments of family members about his condition

Accepted Answer

The answer of The nurse records the following general survey...

Question 14

A man is admitted to the hospital with difficulty breathing.What is the best approach to obtain a health history?&#10;A) Obtain subjective data about the patient from his family members.&#10;B) Delay any subjective data collection,and focus only on his physical examination.&#10;C) Schedule several short sessions with the patient to gather necessary subjective data.&#10;D) Use the physician's medical history as the primary source of subjective data.

Accepted Answer

The answer of A man is admitted to the hospital...

Deck 3: Health History and Physical Examination