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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.
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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.
When assessing the circulation to the lower leg of a patient who has had knee surgery, which action should the nurse take first?
- A. Feel for the temperature of the foot.
- B. Visually inspect the colour of the foot.
- C. Check the patient's pedal pulses using the fingertips.
- D. Compress the nail beds to determine capillary refill time.
Correct Answer: B
Rationale: Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination.
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.
When admitting a patient who has just arrived on the medical unit with severe abdominal pain, what should the nurse do first?
- A. Complete only basic demographic data before addressing the patient's abdominal pain.
- B. Medicate the patient for the abdominal pain before attending to the health history and examination.
- C. Inform the patient that the abdominal pain will be treated as soon as the health history is completed.
- D. Take the initial vital signs and then deal with the abdominal pain before completing the health history.
Correct Answer: D
Rationale: The patient priority in this situation will be to decrease the pain level because the patient will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacological or nonpharmacological therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately.
Immediate surgery is planned for a patient with acute abdominal pain. Which of the following questions will elicit the most complete information about the patient's coping-stress tolerance pattern?
- A. Can you tell me how intense your pain is now?
- B. What do you think caused this abdominal pain?
- C. How do you feel about yourself and your hospitalization?
- D. Are there other major problems that are a concern right now?
Correct Answer: D
Rationale: The coping-stress tolerance pattern includes information about other major stressors confronting the patient. The health perception-health management pattern includes information about the patient's ideas about risk factors. Feelings about self and the hospitalization are assessed in the self-perception-self-concept pattern. Intensity of pain is part of the cognitive-perceptual pattern.