Question 1

While performing percussion in a physical examination, the nurse elicits dullness. Which structure is the nurse likely percussing?. Select all that apply.

Accepted Answer

D,E

Question 2

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?. Select all that apply.

Accepted Answer

C,D,E

Question 3

The nurse is using the technique of inspection during a patient's physical examination. Which findings are possible using this technique?. Select all that apply.

Accepted Answer

Inspection is a technique used in physical examination that involves looking at the patient's body for any signs of health conditions or abnormalities. A) Observing size differences in limbs, B) noting the shape of the abdomen, D) seeing limitations in range of motion, and E) identifying swelling around the eyes are all findings that can be determined through inspection. C) Assessing the strength of a radial pulse, however, involves the technique of palpation, not inspection.

Question 4

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?

Accepted Answer

The nurse is exhibiting the analysis component of critical thinking by recognizing that the patient's blood pressure and symptoms are abnormal and require rapid attention.

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?

Accepted Answer

This type of open-ended question is used to introduce a subject in general terms, allowing the patient to provide a broad response that can guide the direction of the conversation and help the nurse understand the patient's concerns or reasons for the visit without leading them to a specific answer.

Question 6

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?

Accepted Answer

This response shows concern for the patient's safety and opens up the conversation for further exploration of the issue. The nurse can also provide information on resources available for victims of domestic violence. The other choices lack empathy and may discourage the patient from seeking help.

Question 7

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?

Accepted Answer

This choice accurately reflects that the patient is using alternative forms of medicine, specifically yoga and herbal supplements, to manage their back pain. The other choices make assumptions about the patient's beliefs or practices that are not necessarily supported by the information given.

Question 8

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?

Accepted Answer

The nurse and patient are involved in generating alternatives, considering a variety of options to help alleviate the patient's health problem.

Question 9

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

Accepted Answer

After collecting and analyzing data from a patient assessment, the nurse's next step is to formulate nursing diagnoses, which will guide the planning of care and setting of patient care goals.

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?

Accepted Answer

The nurse is making an interpretation by suggesting a possible cause of the patient's shoulder pain. Facilitation, empathy, and summary are not being utilized in this scenario.

Question 11

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?

Accepted Answer

The best response is to explain that wearing gloves during exams is a standard precaution to prevent transmission of infection between the patient and health care provider. This demonstrates professionalism and also educates the patient about infection control measures. Option B is inappropriate and may cause the patient to feel insulted or stigmatized. Option C is not a valid explanation and could make the patient uncomfortable. Option D is not accurate and does not address the patient's question.

Question 12

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?

Accepted Answer

The patient's statement about having trouble getting in and out of the bathtub indicates a potential issue with mobility and functional assessment. The strong, foul body odor could also be related to difficulties with bathing or hygiene. Physical appearance, height, and weight are not directly addressed in this scenario, and while pain may be a factor in the patient's ability to move, it is not specifically mentioned. Nutritional assessment and mental status are not directly related to the information provided.

Question 13

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?

Accepted Answer

The chief complaint is a part of the history of present illness, in which the patient describes the reason for seeking healthcare attention, the symptoms experienced, and the duration of those symptoms.

Question 14

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

Accepted Answer

If a patient is not a reliable historian, it is important to ask different questions to assess the same information. This can help to verify the patient's responses and obtain accurate data for the assessment. It is not appropriate to stop the assessment altogether as some data may still be valid. It is also not appropriate to document that the patient is not answering truthfully without further investigation or evidence to support this claim. Finally, it is important to avoid documenting information that is not accurate or reliable, as this could lead to incorrect diagnoses or treatments.

Question 15

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?

Accepted Answer

Nodding is a nonverbal cue that encourages the patient to continue talking by showing that the nurse is actively listening and engaged in the conversation.

Question 16

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?

Accepted Answer

The patient's report of chest pain and feeling short of breath are subjective data, as they are based on the patient's own experiences and feelings. They cannot be objectively measured or observed by the nurse.

Question 17

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.

Accepted Answer

The answer of A 54-year-old patient reports that she smokes...

Question 18

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?

Accepted Answer

The nurse's action of introducing herself and shaking the patient's hand demonstrates a positive nonverbal message. The nurse's sitting position that maintains eye contact also shows active listening and interest in the patient.

Question 19

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?. Select all that apply.

Accepted Answer

The answer of The nurse is using blunt percussion to...

Question 20

The nurse is preparing to use auscultation as part of a patient's physical examination. Which techniques should the nurse use?. Select all that apply.

Accepted Answer

The diaphragm of the stethoscope is used to hear high-pitched sounds like normal lung sounds. Focusing on one sound at a time helps in accurately identifying and interpreting sounds. The bell is used for low-pitched sounds like heart murmurs.

Quiz 6: Health Assessment