Nokea
The nurse is preparing to perform a focused abdominal assessment for a patient who has high-pitched bowel sounds. Which equipment will be needed?
- A. Flashlight
- B. Stethoscope
- C. Tongue blades
- D. Percussion hammer
Correct Answer: B
Rationale: A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a comprehensive assessment, but will not be needed for a focused abdominal assessment.
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A patient is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time?
- A. Focused
- B. Subjective
- C. Emergency
- D. Comprehensive
Correct Answer: C
Rationale: Since the patient is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the patient is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable patient.
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.
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.
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.
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.