Deck 3: Health History and Physical Examination

Question 1

During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur?

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?"

Answer 1

"Where are you when you have the fainting spells?"

Question 2

When caring for a patient who was admitted a few hours previously with nausea and vomiting, which nursing action can the RN delegate to an LPN/LVN?

A) Ask the patient about any current nausea.
B) Finish documenting the admission assessment.
C) Determine the patient's priority nursing diagnoses.
D) Obtain the health history from the patient's caregiver.

Answer 2

Ask the patient about any current nausea.

Question 3

A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to

A) obtain subjective data about the patient from family members.
B) omit subjective data collection and obtain the physical examination.
C) use the health care provider's medical history to obtain subjective data.
D) schedule several short sessions with the patient to gather subjective data.

Answer 3

schedule several short sessions with the patient to gather subjective data.

Question 4

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

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

Question 5

While the nurse is taking the health history, a patient states, "My father and grandfather both had heart attacks and were unable to be very active afterwards." This statement is related to the functional health pattern of

A) activity-exercise.
B) cognitive-perceptual.
C) coping-stress tolerance.
D) health perception-health management.

Question 6

When assessing the circulation to the lower leg of a patient who has had knee surgery, which action should the nurse take first?

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

Question 7

A patient is seen in the emergency department with chest 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

Question 8

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

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

Question 9

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

A) "Can you tell me how intense your pain is now?"
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 10

As the nurse assesses the patient's neck, the patient says, "My neck is so stiff I can hardly move it." This finding indicates the nurse should perform a(n)

A) focused assessment.
B) screening assessment.
C) emergency assessment.
D) comprehensive assessment.

Question 11

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." Additional information that should be added to this general survey includes

A) nutritional status.
B) intake and output.
C) reasons for contact with the health care system.
D) comments of family members about his condition.

Question 12

When the nurse is planning for the physical examination of an alert 86-year-old patient, adaptations to the examination technique should include

A) speaking slowly when directing the patient.
B) avoiding the use of touch as much as possible.
C) using slightly more pressure for palpation of the liver.
D) organizing the sequence to minimize position changes.

Question 13

A nurse is performing a health history and physical examination for a patient with right-sided rib fractures. The pertinent negative finding is that the patient

A) states that there have been no other health problems recently.
B) denies having pain when the area over the fractures is palpated.
C) has several bruised and swollen areas on the right anterior chest.
D) refuses to take a deep breath because of the associated chest pain.

Question 14

The nurse is preparing to perform a focused abdominal assessment for a patient who has high-pitched bowel sounds. Which equipment will be needed?

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