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Health Assessment Practice Questions

Terms in this set (51)

A 52 year old mail patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission?
a comprehensive assessment
The formation of a plan of care is initiated with:
collection of data
During an interview the nurse learns that a patient has a 5 year history of hypertension. Which health promotion intervention is most appropriate at this time?
Monitoring and minimizing the profession of hypertension
A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What type of data does this information represent?
Subjective and Objective data
Which process does the clustering of data facilitate?
Analyzing data
The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient?
"Tell me about your health care beliefs and practices"
The nurse is conducting an interview with Jeremy, a 17 year old accompanied by his mother. Which statement by the nurse is an age-appropriate adjustment when conducting a health history on an adolescent?
"Mrs. Williams, would you mind waiting outside for a few minutes while I discuss a few things with Jeremy?
During an interview an elderly patient tells the nurse that she has periodic problems keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of symptom analysis is the nurse pursuing with this question?
Aggravating factors
Which communication technique conveys genuine interest in what the patient has to say?
Active listening
A 62 year old patent tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patient's statement?
"Do you use over the counter medications or herbal preparations?"
A school nurse notices a boy with a bandage on his arm and black fluid under the edge of the bandage. She asks the teen what happened to his arm. He replies that his mother applied axle grease to a boil. What is the nurse's most appropriate response to this boy?
Ask the teen what the boil looks like, what it feels like, and if the axle grease is helping it get better
The nurse is caring for a woman who has just been pronounced dead. Her adult children are in the room. Which statement by he nurse indicates culturally competent care?
"Would you like time alone with your mother for any specific ceremonies?"
A nurse is assessing a woman whose religious beliefs do not allow blood transfusions. She has severe anemia, is very weak, and has altered mental status. What behavior by the nurse is needed to provide effective care to this woman?
Examine his or her own feelings about the importance of religious beliefs in making decisions about life
A nurse is teaching a family from Guatemala about the importance of exercise to reduce body weight. The husband asks, "What exercise do we do?" Considering the time orientation of this family, which response by the nurse is most effective?
"Is there an exercise that you can do today for 30 minutes and make it part of your daily routine?"
An older man who is near death has been admitted to the hospital, and family members are at his bedside. During the admission assessment the nurse uses which question or statement to appropriately address spiritual needs?
Are there any special needs or rituals that you and your family request at this time?
What is the most reliable way to assess a patient's pain?
Report from the patient describing the pain experienced
A patient had a knee replaced because of arthritis. He reports that he has not slept well in several nights. He states that he can't get comfortable. Today he is asking for pain medication more often. What might be a reason for this increased pain?
pain tolerance decreases with sleep deprivation
A patient complains of chest pain. Which question is pertinent to ask to gain additional information?
"What does the pain feel like?
A patient complains of leg pain. Which question is pertinent to ask to gain additional information?
"What were you doing when the pain first occurred?"
A female has been admitted to the emergency department with severe abdominal pain. She is lying on a stretcher quietly, with very little movement. The nurse preparing to assess her abdomen should expect to see which behavior when it is time to palpate this patient's abdomen?
Guarding over the abdomen
Which question is appropriate for a nurse to ask at the beginning of a mental health history?
"How have you been feeling about yourself?"
During a history the patient says that she is so uncomfortable with her life that she wishes that it were over. Which is an appropriate follow-up question from the nurse?
"Have you thought of hurting yourself?"
During a health history a patient says, "Stressors? Oh, yeah, I have stressors. I got a promotion at work; and, with the extra income I'm going to move into a new house, bu that has been delayed because my mother is in the hospital and my son is going off to college. To get through this time I just keep using my support systems, exercising, and meditating." How does the nurse interpret these comments by this patient?
Positive coping strategies
Difficulty sleeping, financial concerns, problems with personal or work relationships, difficulty making decisions, tense muscles, and fatigue are indicators of which disorder?
Depression
A patient reports nausea and vomiting; and the nurse observes hand tremors, agitation, and sweating. In view of these findings, which additional data would the nurse need to collect?
When the patient last drank alcohol and how much was consumed.
Why does the nurse ask a patient which medications he takes as part of a nutritional assessment?
The absorption and bioavailability of some medications are affected by food
During a physical examination the nurse is unable to feel the patient's thyroid gland with palpation. What is the appropriate action of the nurse at this time?
Recognize that this is an expected finding
While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss?
Auditory loss
How does the nurse assess a patient's consensual reaction?
By shining a light into the patient's right eye and observing the pupillary reaction of the left eye
What are the characteristics of lymph nodes in patients who have an acute infection?
They are enlarged and tender
Which technique is used for palpating lymph nodes?
Apply gentle pressure over the nodes with the pads of the fingers
During inspection of the respiratory system the nurse documents which finding as abnormal?
Patient leaning forward with arms braced against the knees
A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal fingers are expected?
Fever and tachypnea with crackles over the right lower lobe
On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding?
Rhonchi
How does the nurse palpate the chest for tenderness, bulges and symmetry?
With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae
Which breath sounds are expected over the posterior chest of an adult?
Vesicular
Narrowing of the bronchi creates which adventitious sound?
Wheeze
Which finding may indicate abnormal thoracic expansion?
An S-shaped curvature of the spine
Which patient has the greatest risk for hypertension?
An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two to three alcoholic drinks a night with dinner
When a patient complains of chest pain, which question is pertinent to ask to gain additional data?
"What does the pain feel like?"
On auscultation of the heart, the nurse recognizes which expected finding?
The S1 heart sound is louder at the apex of the heart
A nurse performing an abdominal examination on a 37 year old woman would document which finding as abnormal?
Bulges observed when coughing
Which is an expected finding of an abdominal examination of an adult?
High-pitched gurgles every 5-15 seconds on auscultation
While testing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion?
flexion of the arm
While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements?
Flexion, extension and hyperextension
A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient?
Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and tenderness.
Which finding does the nurse recognize as abnormal when examining a male patient?
Discharge from the penis when the glans is compressed
While taking the health history of a 23 year old female patient, the nurse considers risk factors for STD. Which data from the patient suggest a need for patient education?
The patient states that she has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy
A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem?
Hemorrhoids
Which statement reflects an expected developmental task of a 40 year old man?
"My wife and I have divided the chores with the children since we're both working"
A nurse is assessing an infant who is able to pull up to a sitting position, turn from prone to side position, laugh and babble, and show interest in her surrounds. These behaviors are consistent with an infant of which age?
3 months old
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