Deck 3: Health History and Physical Examination

Question 1

The registered nurse (RN)cares for a patient who was admitted a few hours previously with back pain after falling. Which action can the RN delegate to unlicensed assistive personnel (UAP)?

A)Finish documenting the admission assessment.
B)Determine the patient's priority nursing diagnoses.
C)Obtain the health history from the patient's caregiver.
D)Take the patient's temperature, pulse, and blood pressure.

Answer 1

Take the patient's temperature, pulse, and blood pressure.

Question 2

A patient is seen in the emergency department with severe abdominal pain and hypotension. Which type of assessment should the nurse do at this time?

A)Focused assessment
B)Subjective assessment
C)Emergency assessment
D)Comprehensive assessment

Answer 2

Emergency assessment

Question 3

The nurse plans to complete a physical examination of an alert,older patient. Which adaptations to the examination technique should the nurse include?

A)Avoid the use of touch as much as possible.
B)Use slightly more pressure for palpation of the liver.
C)Speak softly and slowly when talking with the patient.
D)Organize the sequence to minimize the position changes.

Answer 3

Organize the sequence to minimize the position changes.

Question 4

A patient who is actively bleeding is admitted to the emergency department. Which approach is best for the nurse to use to obtain a health history?

A)Briefly interview the patient while obtaining vital signs.
B)Obtain subjective data about the patient from family members.
C)Omit subjective data collection and obtain the physical examination.
D)Use the health care provider's medical history to obtain subjective data.

Question 5

A nurse performs a health history and physical examination with a patient who has a right leg fracture. Which assessment would be a pertinent negative finding?

A)Patient has several bruised and swollen areas on the right leg.
B)Patient states that there have been no other recent health problems.
C)Patient refuses to bend the right knee because of the associated pain.
D)Patient denies having pain when the area over the fracture is palpated.

Question 6

During the health history interview,a patient tells the nurse about periodic fainting spells. Which question by the nurse will best elicit any associated clinical manifestations?

A)"How frequently do you have the fainting spells?"
B)"Where are you when you have the fainting spells?"
C)"Do the spells tend to occur at any special time of day?"
D)"Do you have any other symptoms along with the spells?"

Question 7

When assessing for formation of a possible blood clot in the lower leg of a patient,which action should the nurse take first?

A)Visually inspect the leg.
B)Feel for the temperature of the leg.
C)Check the patient's pedal pulses using the fingertips.
D)Compress the nail beds to determine capillary refill time.

Question 8

The nurse who is assessing an older adult with rectal bleeding asks,"Have you ever had a colonoscopy?" The nurse is performing what type of assessment?

A)Focused assessment
B)Emergency assessment
C)Detailed health assessment
D)Comprehensive assessment

Question 9

The nurse is preparing to perform a focused assessment for a patient complaining of shortness of breath. Which equipment will be needed?

A)Flashlight
B)Stethoscope
C)Tongue blades
D)Percussion hammer

Question 10

When assessing a patient's abdomen during the admission assessment,which action should the nurse take first?

A)Feel for any masses.
B)Palpate the abdomen.
C)Listen for bowel sounds.
D)Percuss the liver borders.

Question 11

While the nurse is taking the health history,a patient states,"My mother and sister both had double mastectomies and were unable to be very active for weeks." Which functional health pattern is represented by this patient's statement?

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

Question 12

When admitting a patient who has just arrived on the unit with a severe headache,what should the nurse do first?

A)Complete only basic demographic data before addressing the patient's pain.
B)Inform the patient that the headache will be treated as soon as the health history is completed.
C)Medicate the patient for the headache before doing the health history and examination.
D)Take the initial vital signs and then address the headache before completing the health history.

Question 13

In what order will the nurse perform these actions when doing a physical assessment for a patient admitted with abdominal pain? (Put a comma and a space between each answer choice [A,B,C,D].)

A)Percuss the abdomen to locate any areas of dullness.
B)Palpate the abdomen to check for tenderness or masses.
C)Inspect the abdomen for distention or other abnormalities.
D)Auscultate the abdomen for the presence of bowel sounds.

Question 14

Immediate surgery is planned for a patient with acute abdominal pain. Which question by the nurse will elicit the most complete information about the patient's coping-stress tolerance pattern?

A)"Can you rate your pain on a 0 to 10 scale?"
B)"What do you think caused this abdominal pain?"
C)"How do you feel about yourself and your hospitalization?"
D)"Are there other major problems that are a concern right now?"

Question 15

The nurse records the following general survey of a patient: "The patient is a 50-yr-old Asian female attended by her husband 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 the nurse add to this general survey?

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