Health Asses Part 3

A patient has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the patient interview. Which of the following activities should the nurse perform first? • Collaborate with the patient to identify problems. • Explain the purpose of the interview. • Determine the patient's vital signs. • Obtain family health history data. • During the interview, the patient states, “Is today the 12th? My wife died 2 months ago today.” Which of the following responses would be most appropriate? • “What was the cause of your wife's death?” • “How does that make you feel right now?” • “You probably must be sad.” • “Are you feeling sad, depressed, angry, or upset?” • The nurse is using the mnemonic “COLDSPA” to assess a patient's complaint of lower abdominal pain. The nurse asks the patient to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? • Character • Onset • Severity • Pattern • The nurse is obtaining information about a patient's past health history. Which patient statement would best reflect this component of assessment? • “My mom's still alive, but my dad died 10 years ago of heart failure.” • “I have a brother with leukemia and a sister with hypertension.” • “I had surgery 5 years ago to repair an inguinal hernia.” • “I have been having some pain when I urinate for the last several days.” • A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during patient care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? • Maintaining an open attitude • Using silence appropriately • Providing a laundry list of descriptors when needed • Maintaining an open and encouraging facial expression • The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginning with the section obtained first. • Family health history • Reason for seeking care • Biographic data • Review of body systems • History of present concern • Past health history C,B,E,F,A,D • The nurse is completing a review of systems for a patient. Which of the following information would the nurse document related to the patient's musculoskeletal system? Select all that apply. • Joint stiffness • Shortness of breath • Chest pain • Muscle strength • Knee swelling • The nurse is completing an assessment of a 50-year-old female patient who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment? • “patient's gastrointestinal health is within reference ranges for age.” • “patient denies GI signs and symptoms.” • “Gastrointestinal problems are absent.” • “patient denies recent constipation, diarrhea, bowel incontinence, or abdominal pain.” • A 60-year-old woman with a bunion will undergo surgery later today. The patient tells the nurse in the surgical daycare admitting department, “I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?” How should the nurse best explain the rationale for obtaining a health history? • “In general, it's necessary for us to gather as much information about each patient as possible.” • “We want to make sure your nursing care matches your needs as closely as possible.” • “The care team needs to cross-reference your diagnostic testing with the information that I'm asking you about.” • “We don't want to make the mistake of focusing solely on the medical problem that brought you here.” • During the nurse's assessment of the patient's exercise and activity habits, the patient laughs and then states, “Unless you're including channel surfing, I don't really do much of anything.” How should the nurse best follow up this patient's statement? • Briefly describe some of the potential benefits of regular exercise. • Ask the patient if he understands the risk factors for heart disease and diabetes. • Explain to the patient that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week. • Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle. • A nurse is obtaining subjective data from an adult patient who is new to the clinic. The nurse has asked the patient, “Where do you usually turn for help in a time of crisis?” What domain is this nurse assessing? • The patient's family relationships • The patient's current level of social and relational stability • The patient's critical thinking and problem-solving abilities • The patient's stress management and coping strategies• A patient has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam? • Explain the purpose of the interview to the patient. • Construct the patient's family genogram. • Establish the patient's reliability as historian. • Collect necessary equipment essential to the exam. • A young adult patient has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a patient's anxiety during the physical exam. Which of the following would be most appropriate? • Ensuring patient's privacy by providing an examination gown • Providing a comfortable, warm room temperature • Arranging exam equipment on a bedside tray table • Explaining why standard precautions are being used • A nurse is admitting a new patient to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions? • Performing hand hygiene between examinations of each body part • Discarding in the trash can the safety pin that was used to assess sensory perception • Wearing gloves to palpate the tongue and buccal membranes • Wearing a gown, gloves, and mask during the physical exam • The nurse is using a Wood's light for a patient who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the patient's symptoms? • Parasitic infection • Fungal infection • Bacterial infection • Allergic reaction • A nurse has gathered the necessary equipment for the physical assessment of an adult patient. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? • Mid-arm circumference • patient's height • Skin lesion size • Pupillary size • The nurse is preparing to assess an older adult patient's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use? • Newspaper • Snellen chart • Ophthalmoscope • Penlight • A nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? • Parasites • Blood • Bacteria • Fungus • The nurse is examining an older adult patient and using a goniometer. Which of the following would the nurse be assessing? • Extremity edema • Joint flexion/extension • Two-point discrimination • Vibratory sensation • A female patient is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There's no way I'll let you do that to me!î Which response by the nurse would be most appropriate? • Explain the importance of the pelvic exam and Pap smear, but respect the patient's wishes and omit the exam. • Tell the patient that this is the only way she can be checked for cancer. • Ask the patient if she would prefer another practitioner to perform the exam. • Proceed with the pelvic exam and document the patient's protests in the health record. • The nurse is preparing to perform a physical examination on a female patient who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations? • Head and neck examination • Palpation of lymph nodes • Breast examination • Vital signs • The nurse is to collect a throat culture from a patient who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment? • Eye goggles • Face mask • Cover gown • Face shield • The nurse is preparing to perform the physical examination of an older adult patient who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate? • Omit intrusive parts of the exam. • Try to minimize position changes. • Allow patient to remain dressed. • Dim the room light to ensure privacy. • The nurse is preparing to assess the peripheral pulses of a patient. The nurse should place the patient in which position? • Sitting upright • Supine • Sims position • Prone • When assessing the temperature of the feet of an older patient with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data? • Finger pad surface • Palmar hand surface • Dorsal hand surface • Ulnar hand surface • A patient has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions? • Use one hand and depress the skin 1 centimeter. • Use the dominant hand to depress the skin one-half to three-quarters of an inch. • Use both hands to depress the skin one-half of an inch. • Use both hands to depress the skin 1 to 2 inches.