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Chapter 20 - Health History and Physical Assessment
Terms in this set (30)
On auscultation of the heart of a 30-year-old patient, the nurse detects an audible fourth heart sound. Which action should the nurse take? Select all that apply.
A. Consider it an abnormal heart sound.
B. Obtain an order for angiography.
C. Inform the health care provider.
D. Wait for 24 hours and auscultate again.
E. Ask the patient if he or she is an athlete.
A, C, E
How do certain conditions affect skin turgor? Select all that apply.
A. Age is indirectly proportional to skin turgor.
B. Body fluid levels affect skin turgor.
C. Dehydration decreases skin turgor.
D. Edema increases skin turgor.
E. Scarring increases skin turgor.
A, B, C
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? Select all that apply.
A. A normal pulse on the top of the foot indicates adequate blood flow to the foot.
B. The best place to assess the dorsalis pedis pulse is behind the knee.
C. When there is poor arterial blood flow, the leg is generally warm to the touch.
D. Loss of hair on an extremity indicates a long-term problem with arterial blood flow.
E. Extremities with insufficient arterial blood flow may feel numb or tingly.
Which risk factors may contribute to the development of glaucoma in a patient? Select all that apply.
A. Increased age
D. Low blood pressure
A, B, C, D
The nurse finds that an older adult patient has a sudden onset of confusion. Which factors in the patient's health history should the nurse review as possible causes? Select all that apply.
B. Medication use
C. Caffeine intake
D. Heart failure
E. Congenital anomalies
A, B, D
A patient reports that a mole on the face has recently changed shape. To screen for melanoma, which additional characteristics of the mole would the nurse inspect? Select all that apply.
A, B, C, D
During an assessment of the musculoskeletal system, the nurse finds that the patient requires assistance to achieve full range of motion (ROM) in the extremities and that the muscles feel loose and flaccid. Which statement should the nurse include in documentation of these findings?
A. Moves all extremities with active ROM
B. Hypertonicity with passive ROM
C. Hypotonicity with active ROM
D. Hypotonicity with passive ROM
Which skin color alteration is characterized by lightened skin tone of areas such as the face, oral mucosa, nailbeds, palms of hands, and conjunctiva of the eye?
Which physical assessment finding is typical of arterial insufficiency?
A. Marked edema
B. Warmth in the affected area
C. Diminished or absent pulses
D. Reddened skin color in the affected area
Which finding suggests that a patient may be suffering from a chronic cardiac or pulmonary condition?
A. Graying of the hair
B. Clubbing of the fingers
C. Yellow-colored sclera
D. Callus formation on heels
Which intervention should the nurse perform when using palpation during a general physical examination?
A. Palpate tender areas first.
B. Ask the patient to take shallow breaths.
C. Instruct the patient to keep both hands on the abdomen.
D. Warm the hands and use a gentle approach.
The nurse is teaching a patient about the various cranial nerves to help explain why the patient's mouth droops instead of moving up into a smile. The nurse explains that which cranial nerve is responsible for the motor function of the mouth?
D. XI—Spinal accessory
The nurse is teaching a patient about testicular self-examination. Which statement by the nurse is correct?
A. "The testes should feel smooth and pliable."
B. "Testicular cancer is usually detected as a painful lump."
C. "Testicular self-examination is not necessary if you get regular physical examinations."
D. "Nodules on the testes are not abnormal."
In which areas of the body is cyanosis most easily assessed? Select all that apply.
A. Mucous membranes
C. Sclera of the eye
E. Inside the throat
A, B, D
Which condition is suspected when an adult with congenital heart disease reports the development of clubbed fingernails over the past few years?
A. Untreated nail fungus
B. Chronic hypoxia
C. Inherited nail abnormality
Which body areas should the nurse inspect for jaundice? Select all that apply.
B. Hard palate
D. Tip of the nose
Which actions should the nurse take to ensure effective inspection of a patient during regular physical examination? Select all that apply.
A. Make sure that adequate lighting is available.
B. Use a penlight or lamp to inspect body cavities.
C. Inspect each area for size, shape, color, position, and abnormality.
D. Expose the patient completely head to toe for easy inspection.
E. Check for side-to-side symmetry.
A, B, C, E
The nurse documents that a hospitalized patient is alert and oriented × 4. This indicates that the patient can identify which facts about themselves? Select all that apply.
A. Current location
B. Current situation
C. Full name
D. Current time
E. Current diagnosis
A, B, C, D
Which strategies to prevent cataracts does the nurse include in a patient teaching session? Select all that apply.
A. Quitting smoking
B. Limiting alcohol consumption
C. Eating a diet rich in vitamin E
D. Wearing sunglasses when outside
E. Wearing bifocal lenses for reading
A, B, C, D
During auscultation of breath sounds, the nurse hears low, soft, blowing normal breath sounds over most of the lung fields. The nurse documents this finding as which type of breath sound?
Which questions asked by the nurse during assessment encourage a patient to provide a narrative description of his or her cancer treatment-related symptoms? Select all that apply.
A. "Can you share with me your symptoms since beginning your cancer treatment?"
B. "Describe for me how your symptoms affect your daily life."
C. "Let's focus on your pain. Tell me how it affects you."
D. "Are you satisfied with the management of your nausea?"
E. "Do your family members assist you with your care following treatments?"
A, B, C
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS). Which precautions should the nurse take to ensure that the assessment is accurate? Select all that apply.
A. Make sure the patient is as alert as possible.
B. Monitor sensory losses.
C. Perform the test in front of a family member.
D. Obtain a signed, informed consent from the patient.
E. Obtain a health care provider's order.
Which assessment techniques are appropriate for assessing hydration in a patient? Select all that apply.
A. Inspect the lips and mucous membranes to determine if they are moist.
B. Pinch the skin on the back of the hand to see if the skin tents.
C. Check the patient's pulse and blood pressure.
D. Weigh the patient daily.
E. Palpate the patient's skin lightly to determine texture.
A, B, C, D
How would the nurse assess the function of the oculomotor nerve in a patient? Select all that apply.
A. Test the six directions of gaze.
B. Measure accommodation reflex.
C. Measure pupillary reaction to light.
D. Provide a Snellen chart and test acuity.
E. Provide a newspaper and ask the patient to read.
A, B, C
The nurse is obtaining a patient's health history. Which actions indicate that the nurse is attentive while conducting the patient interview? Select all that apply.
A. Tapping a hand on the table
B. Frequently glancing at the clock
C. Leaning slightly toward the patient
D. Maintaining eye contact with the patient
E. Looking into the medical records while talking
Which instructions does the nurse include while teaching a female patient about measures to reduce the risk of breast cancer? Select all that apply.
A. Maintain a body mass index of less than 25.
B. Limit physical activity to 1 to 2 hours per week.
C. Quit cigarette smoking.
D. It is okay to drink 2 alcoholic drinks daily.
E. Increase fruit and vegetable intake.
A, C, E
During physical examination, light abdominal palpation is an effective technique to assess which conditions of the abdomen? Select all that apply.
A. Presence of hernia
B. Abnormal muscle integrity
C. Presence of an intestinal infection
E. Presence of urinary bladder distention
A, B, E
Which factors should be noted as part of the general survey component of physical assessment? Select all that apply.
B. Lung sounds
C. Body odor
D. Signs of abuse
A, C, D, E
A nurse gently grasps a fold of skin over the patient's sternum and then releases. The patient's skin stays pinched. What should this indicate to the nurse about the patient's hydration status?
C. Adequately hydrated
D. Excessively hydrated
Which statements would the nurse include in teaching colleagues about spinal abnormalities? Select all that apply.
A. Scoliosis is the medial deviation and plantar flexion of the foot.
B. Kyphosis is the increased convexity in curvature of thoracic spine.
C. Kyphosis is the internal rotation of the forefoot or entire foot.
D. Lordosis is the exaggeration of the anterior convex curve of lumbar spine.
E. Scoliosis is a lateral S- or C-shaped spinal column with vertebral rotation.
B, D, E
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