Nokea
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.
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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.
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.
While the nurse is taking the health history, a patient states, 'My father and grandfather both had heart attacks and were unable to be very active afterwards.' This statement reflects which of the following functional health patterns?
- A. Activity-exercise
- B. Cognitive-perceptual
- C. Coping-stress tolerance
- D. Health perception-health management
Correct Answer: D
Rationale: The information in the patient statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception-health maintenance pattern.
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.
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.