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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.
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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.
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.
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.
The nurse records the following general survey of a patient: 'The patient is a 78-year-old Asian female accompanied by her two daughters. Alert and oriented. Does not make eye contact with the nurse and responds appropriately to questions. No apparent disabilities or distinguishing features.' Which of the following information should be added to this general survey documentation?
- A. Nutritional status
- 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: The general survey also describes the patient's general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.
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.