Question 1

A student nurse is preparing to auscultate a patient's lungs. What action by the student leads the instructor to intervene?

Accepted Answer

The diaphragm is used to listen to bowel sounds. The other actions are appropriate.

Question 2

The nurse is assessing a patient's cranial nerve III. What technique is best?

Accepted Answer

Cranial nerve III (oculomotor nerve) is assessed by observing the patient's pupil size and reaction to light and the direction of gaze. Identifying a common scent would test cranial nerve I. Assessing the patient's visual acuity tests cranial nerve II. Assessing hearing is cranial nerve VIII.

Question 3

A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best?

Accepted Answer

For patient safety, some patients should never be left alone on an examination table: infants; small children; older adults who are confused, combative, or uncooperative, and people who are physically or chemically restrained. The nurse calls for another staff member to get the missing equipment. Getting up and down off the table is inconvenient and may be difficult. Finishing the exam and then retrieving the piece of equipment also involves the patient changing locations and is inconvenient for the patient.

Question 4

A nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best?

Accepted Answer

The lithotomy position is used to examine female genitalia. It is an uncomfortable and embarrassing position, so the nurse ensures time spent in that position is limited. The nurse gets the provider, then assists the patient into the position. The Sims position is used to examine the rectal and perineal areas.

Question 5

A nurse is assessing a patient's cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best?

Accepted Answer

Cranial nerve VI (abducens) is responsible for outward gaze of the eyes. Abnormal findings could indicate a fracture of the orbit or a brain tumor. The nurse asks the patient questions related to these two conditions. The provider needs to be informed and the nurse must document, but first the nurse conducts a thorough assessment. Frowning and lifting the eyes assesses cranial nerve VII.

Question 6

A nurse is told in handoff report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient's Glasgow Coma Scale to be?

Accepted Answer

This patient's eye opening would be scored 4, verbal response would be 4, and motor response would be scored at 5; this equals a score of 13.

Question 7

The nurse is planning to educate four patients on preventing skin cancer and early warning signs. Which patient is the priority for this education?

Accepted Answer

Research indicates that indoor tanning increases the risk of developing skin cancer by 75%. The adolescent who tans is the highest priority for this education. The others do not have as high a risk.

Question 8

A nurse has conducted an Allen's test on a patient and the result was 8 seconds. What action by the nurse is best?

Accepted Answer

After the hand blanches in an Allen's test, when the nurse releases the pressure, normal color should return within 10 seconds. This patient's findings were normal, so the nurse should document the results and continue with the assessment. The other actions are not needed.

Question 9

A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process? (Select all that apply.)

Accepted Answer

During the interview process, the nurse needs to demonstrate interest in the patient by leaning slightly toward him/her, allowing requested family or friends to accompany the patient, and closing the door to the room to ensure privacy. Typing intently when the patient is talking can be interpreted as lack of interest. Providing non-verbal cues to the nurse's negative thoughts (such as scowling when the patient mentions something negative) does not promote comfort or trust.

Question 10

A nurse is assessing a patient's abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?

Accepted Answer

These findings are normal; it may take up to 30 seconds of listening to hear bowel sounds. The nurse documents the findings; no other action is needed.

Question 11

The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best?

Accepted Answer

To prevent cross contamination, the healthy eye is examined before the diseased eye.

Question 12

A nurse assesses a patient's lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best?

Accepted Answer

The patient has rhonchi. Rhonchi are caused by increased secretions in large airways and can be seen in pneumonia or in other conditions, leading to increased mucus production. The nurse prepares to treat the patient for pneumonia. Asthma would manifest with wheezing, coup with stridor, and heart failure with rales or crackles.

Question 13

A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate?

Accepted Answer

The important fact in this question is that the patient is partly undressed and the nurse provides a means to keep the patient warm. All answers are appropriate for any examination, but keeping the patient warm is specific to this situation.

Question 14

A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best?

Accepted Answer

This patient has manifestations of a deep vein thrombosis, and the nurse should not massage the patient's legs. The nurse should inform the patient of why this is contraindicated. The other actions are not warranted.

Question 15

The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate?

Accepted Answer

A paronychia is inflammation at the base of the nail so the nurse assesses the patient's nails and the surrounding skin. The other assessments are not related to this diagnosis.

Question 16

A nurse has assessed a patient's capillary refill, which was 5 seconds. What action by the nurse is most appropriate?

Accepted Answer

Normal capillary refill is 2 to 3 seconds. Prolonged capillary refill can indicate hypoxia, anemia, or circulatory insufficiency. The nurse should document the findings, but further action is not needed. Asking about artificial nails and occupation are not warranted.

Question 17

A patient wishes to review his medical record. What response by the nurse is best?

Accepted Answer

Patients have the right to look at their records. It is best if a health care provider is present in order to answer any questions the patient may have or to help interpret any information found within the record.

Question 18

A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best?

Accepted Answer

This patient is sitting in a tripod position, often seen in patients with chronic obstructive pulmonary disease. These patients also often have a barrel-chest appearance, so the nurse assesses for this finding. The other actions are not related to a tripod position.

Question 19

The nurse is assessing a patient's alcohol intake. What question is most appropriate?

Accepted Answer

The nurse needs to be non-judgmental when inquiring about topics that might be sensitive, such as alcohol or drug use. The nurse asks a neutral, objective question such as "How much alcohol do you drink daily?" that allows the patient to quantify the intake. Avoid yes/no questions because they are closed ended and do not lead to further discussion or disclosure. Avoid a negatively charged question such as, "You don't drink much, do you?"; this demonstrates the nurse's displeasure with drinking. Asking when the last drink was is not as important in a general survey as quantifying the amount of intake.

Question 20

The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best in order to hear the murmur?

Accepted Answer

A Grade 3 murmur should be readily heard with a regular stethoscope. Although the room should be quiet for all auscultation tasks, an "extremely" quiet room and an amplification stethoscope should not be necessary. The bell of the stethoscope is usually used to listen to heart murmurs, but the stethoscope needs to be on the patient's chest.

Quiz 20: Health History and Physical Assessment