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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.
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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.
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.
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.
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.
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.