Nokea
A nurse is performing a health history and physical examination for a patient with right-sided rib fractures. Which of the following data is a pertinent negative finding?
- A. Patient states that there have been no other health problems recently.
- B. Patient denies having pain when the area over the fractures is palpated.
- C. Patient has several bruised and swollen areas on the right anterior chest.
- D. Patient refuses to take a deep breath because of the associated chest pain.
Correct Answer: B
Rationale: The nurse expects that a patient with rib fractures will have pain over the fractured area. The first statement is neither a positive nor a negative finding with regard to the rib fractures. The bruising and swelling and pain with breathing are positive findings.
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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
Correct Answer: B
Rationale: A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a comprehensive assessment, but will not be needed for a focused abdominal assessment.
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?
Correct Answer: B
Rationale: Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology, frequency, and associated clinical manifestations.
An older-adult patient who is having difficulty breathing is admitted to the hospital. Which of the following approaches is the best for the nurse to use to obtain a complete health history?
- 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.
Correct Answer: D
Rationale: In the case of an older-adult patient with a low energy level, several short sessions may have to be scheduled. Allowing time for the patient to volunteer information about particular areas of concern enables the nurse to work with the patient to identify existing and potential health problems. In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider's medical history. Family members may be able to provide some subjective data, but only the patient will be able to give subjective information about the shortness of breath. Since the subjective data about the patient's respiratory status will be essential, obtaining the physical examination alone will not provide sufficient information.
As the nurse assesses the patient's neck, the patient says 'My neck is so stiff I can hardly move it.' This patient statement indicates the nurse should perform which of the following assessments?
- A. Focused
- B. Screening
- C. Emergency
- D. Comprehensive
Correct Answer: A
Rationale: The focused assessment is needed when a patient has clinical manifestations that indicate a problem. An emergency assessment is done when the nurse needs to obtain information about life-threatening problems quickly while simultaneously taking action to maintain vital function. The screening assessment is not recognized as one of the three main types of assessment. A comprehensive assessment is a detailed health history and physical examination.
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
- B. Subjective
- C. Emergency
- D. Comprehensive
Correct Answer: C
Rationale: Since the patient is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the patient is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable patient.