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In your role as a school nurse, you are performing a sports physical on a healthy adolescent girl who is planning to try out for the volleyball team. When it comes time to listen to the students heart and lungs, what is your best nursing action?
- A. Perform auscultation with the stethoscope placed firmly over her clothing to protect her privacy.
- B. Perform auscultation by holding the diaphragm lightly on her clothing to eliminate the scratchy noise.
- C. Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise.
- D. Defer the exam because the girl is known to be healthy and chest auscultation may cause her anxiety.
Correct Answer: C
Rationale: Auscultation should always be performed with the diaphragm placed firmly on the skin to minimize extra noise and with the bell lightly placed on the skin to reduce distortion caused by vibration. Placing a stethoscope over clothing limits the conduction of sound. Performing auscultation is an important part of a sports physical and should never be deferred.
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A patient has a newly diagnosed heart murmur. During the nurses subsequent health education, he asks if he can listen to it. What would be the nurses best response?
- A. Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur.
- B. Listening is called palpation, and I would be glad to help you to palpate your murmur.
- C. Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction.
- D. If you would like to listen to your murmur, Id be glad to help you and to show you how to use a stethoscope.
Correct Answer: D
Rationale: Listening with a stethoscope is auscultation and it is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs, whereas the bell is used to assess low-frequency sounds such as diastolic heart murmurs. It is also important to provide education whenever possible and actively include the patient in the plan of care. Teaching an interested patient how to listen to a murmur should be encouraged. Many heart murmurs are benign and do not require surgery.
The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems?
- A. Allergies
- B. Alcoholism
- C. Psoriasis
- D. Hypervitaminosis
- E. Obesity
Correct Answer: A,B,E
Rationale: In general, the following conditions are included in a family history: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies ???¾?±?????²?µ?½?½?¾?¹, alcoholism, and obesity. Psoriasis and hypervitaminosis do not have genetic etiologies.
You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?
- A. The patient may be at risk for developing diabetes.
- B. The patient may need teaching on the effects of diabetes.
- C. The patient may need to attend a support group for individuals with diabetes.
- D. The patient may benefit from a dietary regimen that tracks glucose intake.
Correct Answer: A
Rationale: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.
You are conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?
- A. Availability of home health care, current Medicare rules, and family support
- B. The community and home environment, support systems or family care, and the availability of needed resources
- C. The future health status of the individual, and community and hospital resources
- D. The characteristics of the neighborhood, and the patients socioeconomic status and insurance coverage
Correct Answer: B
Rationale: The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. The other options fail to address the specifics of either the community or home environment.
The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?
- A. Have a family member provide the data.
- B. Obtain the data from the old chart and physicians assessment.
- C. Obtain the data only from the patient, prioritizing aspects that the patient understands.
- D. Collect all possible data from the patient and have the family supplement missing details.
Correct Answer: D
Rationale: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.