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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.
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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.
When assessing a patient's abdomen during the admission assessment, which of these actions should the nurse take first?
- A. Feel for any masses.
- B. Palpate the abdomen.
- C. Percuss the liver borders.
- D. Listen to the bowel sounds.
Correct Answer: D
Rationale: When assessing the abdomen, auscultation is done before palpation or percussion because palpation and percussion can cause changes in bowel sounds and alter the findings. All of the techniques are appropriate, but auscultation should be done first.
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.
The nurse records the following general survey of a patient: 'The patient is a 68-year-old Indigenous male accompanied by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.' Which of the following areas does the nurse need to assess to complete the general survey?
- A. Body movements
- B. Intake and output
- C. Reasons for contact with the health care system
- D. Comments of family members about his condition
Correct Answer: A
Rationale: To complete a general survey, the nurse needs to assess the patient's body movements. Intake and output, reasons for contact with the health care system, and comments of family members about the patient's condition are not part of the general survey.
The nurse is completing a neurological assessment on an adult patient. Which of the following assessments should the nurse include when assessing the patient's coordination?
- A. Toe walk
- B. Finger to nose
- C. Drift
- D. Romberg
- E. Heel to opposite shin
Correct Answer: B,D,E
Rationale: A neurological assessment is completed to observe motor status by assessing gait, toe and heel walk, and drift, whereas when assessing coordination, the nurse observes finger to nose, Romberg sign, and heel to opposite shin.