Deck 6: Health Assessment

Question 1

The nurse and a patient are discussing a variety of options that may help alleviate a health problem. The nurse and patient are involved in which step of the critical thinking process?

A) Evaluation
B) Collection of information
C) Generation of alternatives
D) Analysis of the situation

Answer 1

Generation of alternatives

Question 2

Prior to palpating the abdomen of a patient with several skin lesions, the nurse puts on a pair of gloves. The patient asks, "What are the gloves for?" Which is the best response the nurse can give the patient?

A) "Gloves are considered a standard precaution to provide protection to the health care provider during an exam."
B) "I don't want to catch anything from you."
C) "I prefer to wear gloves when touching people."
D) "The gloves help me to grip my equipment better."

Answer 2

"Gloves are considered a standard precaution to provide protection to the health care provider during an exam."

Question 3

The nurse is using blunt percussion to assess a patient who was involved in a motor vehicle accident. The nurse would use this technique to assess for injury to which organs? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Kidney
B) Liver
C) Lungs
D) Bladder
E) Heart

Answer 3

Kidney
Liver

Question 4

The nurse is reviewing the outcomes of a patient's plan of care. Which portions of the critical thinking process are used in this evaluation? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Revision of cues
B) Generation of alternatives
C) Analysis of the situation
D) Selection of alternatives
E) Collection of information

Question 5

The nurse asks the patient, "What brings you to the hospital today?" What is the nurse's rationale for using this type of question?

A) It acknowledges agreement between the patient and the nurse.
B) It elicits specific information.
C) It is useful for introducing a subject in general terms.
D) It helps to clarify information.

Question 6

A 54-year-old patient reports that she smokes a pack and a half of cigarettes daily and has been smoking since she was 16 years old. The nurse would record a smoking history of ______ pack-years.

Question 7

The nurse is preparing to use auscultation as part of a patient's physical examination. Which techniques should the nurse use? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Pressing the bell of the stethoscope firmly on the skin to hear muffled tones
B) Using the diaphragm of the stethoscope to hear normal lung sounds
C) Placing the diaphragm of the stethoscope firmly against the patient's gown
D) Focusing on one sound at a time
E) Using the bell of the stethoscope to hear low-pitched sounds

Question 8

While performing percussion in a physical examination, the nurse elicits dullness. Which structure is the nurse likely percussing? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Intestines
B) Lungs
C) Pelvic bone
D) Liver
E) Kidney

Question 9

While conducting a health assessment, the nurse documents a patient's response under the heading "chief complaint." Which part of the assessment is the nurse conducting?

A) History of present illness
B) Family history
C) Psychosocial history
D) Past medical history

Question 10

During an assessment, the patient describes shoulder pain. The nurse responds, "So, you have this shoulder pain when you eat fried foods or ice cream, is that correct?" The nurse is using which interview technique?

A) Facilitation
B) Empathy
C) Interpretation
D) Summary

Question 11

Using critical thinking, the nurse assesses that a patient is not a reliable historian. How should the nurse proceed?

A) Stop the assessment because all data is invalid.
B) Document that the patient is not answering questions truthfully.
C) Ask different questions to assess the same information.
D) Document the information just as the patient reports it.

Question 12

A patient in the unit has a blood pressure of 55/30, is lethargic, has slurred speech, and is unable to get back to bed from the bathroom. The nurse calls for a rapid response team. Which component of critical thinking is the nurse exhibiting?

A) Analysis of situation, distinguishing normal from abnormal
B) Selection of alternative by developing outcomes and plans
C) Collection of information, subjective and objective
D) Evaluation of situation, determination of outcomes achieved

Question 13

During the health history, a patient tells the nurse that she is in an abusive relationship and is fearful of getting hurt if her husband finds out that she told the nurse. Which response by the nurse is most appropriate for this patient?

A) "Don't worry. They only strike back when they are angry."
B) "Are you saying that you are in danger?"
C) "I would get an attorney if I were you."
D) "Remember, what goes around comes around."

Question 14

The nurse introduces herself and shakes the patient's hand, then sits so as to maintain eye contact during the health interview. What do the nurse's actions demonstrate?

A) Facilitation
B) Negative nonverbal messages
C) Positive nonverbal messages
D) Empathy

Question 15

A patient comes to the emergency department and states, "I am having chest pain and I feel short of breath." How is the data the patient has just given the nurse classified?

A) Nonspecific
B) Objective
C) Factual
D) Subjective

Question 16

The nurse has completed the collection and analysis of data from a patient assessment. What is the nurse's next action?

A) Evaluate outcomes from care.
B) Plan care.
C) Determine patient care goals.
D) Formulate nursing diagnoses.

Question 17

The nurse notices a patient has a strong, foul body odor. The patient tells the nurse he has trouble getting in and out of the bathtub. Which areas of the physical assessment does this information address?

A) Behavior and pain
B) Nutritional assessment, mental status, and behavior
C) Physical appearance, height, and weight
D) Functional assessment, physical appearance, and mobility

Question 18

A patient tells the nurse that he has a history of back pain that is controlled with yoga and herbal supplements. How would the nurse document this information?

A) The patient does not believe in Western medicine.
B) The patient has strong spiritual beliefs.
C) The patient uses some alternative forms of medicine to treat illness.
D) The patient uses stress reduction techniques to control back pain.

Question 19

While conducting a health history, the nurse nods her head as the patient is talking. What is the nurse's primary rationale for this action?

A) It conveys acknowledgment of the patient's feelings.
B) It helps to reduce the patient's anxiety level.
C) It encourages the patient to continue talking.
D) It allows the nurse time to observe the patient's nonverbal cues.

Question 20

The nurse is using the technique of inspection during a patient's physical examination. Which findings are possible using this technique? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient's left leg is larger than the right leg.
B) The patient's abdomen is scaphoid.
C) The patient has a strong radial pulse.
D) The patient has difficulty extending the right arm above the head.
E) The patient has periorbital edema.