Nokea
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.
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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.
When the nurse is planning for the physical examination of an alert older-adult patient, which of the following adaptations to the examination technique should be considered?
- A. Speaking slowly when directing the patient
- B. Avoiding the use of touch as much as possible.
- C. Using slightly more pressure for palpation of the liver.
- D. Organizing the sequence to minimize position changes.
Correct Answer: D
Rationale: Older patients may have age-related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older patients. Less pressure should be used over the liver. Since the patient is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse.
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.
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 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.