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You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint?
- A. Why do you think your abdomen is painful?
- B. Where exactly is your abdominal pain and when did it start?
- C. What brings you to the hospital today?
- D. What is wrong with you today?
Correct Answer: C
Rationale: The chief complaint should clearly address what has brought the patient to see the health care provider; an open-ended question best serves this purpose. The question What brings you to the hospital? allows the patient sufficient latitude to provide an answer that expresses the priority issue. Focusing solely on abdominal pain would be too specific to serve as the first question regarding the chief complaint. Asking, What is wrong with you today? is an open-ended question but still directs the patient toward the fact that there is a problem.
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You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?
- A. Is anyone physically hurting you?
- B. Tell me about your relationships.
- C. Do you want to see a social worker?
- D. Is there something you want to tell me?
Correct Answer: A
Rationale: Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you? The other options are incorrect because they are not the best way to illicit information about possible abuse in a direct and appropriate manner.
A nurse practitioner's assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which Anya of the following is the nurse able to assess?
- A. Borders of the patient's heart
- B. Movement of the patient's diaphragm during expiration
- C. Borders of of the patient's liver
- D. The presence of rectal distension
Correct Answer: A
Rationale: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. Movement of the diaphragm, delineation of the liver, and the presence of rectal distention cannot be assessed by percussion.
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.
An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question?
- A. Tell me about your medications: How do you usually get them each day?
- B. Tell me about where you live: Do you feel your needs are being met, and do you feel safe?
- C. Your wheelchair would seem to limit your ability to move around. How do you deal with that?
- D. What limitations are you dealing with related to your health and being in a wheelchair?
Correct Answer: B
Rationale: The question, Tell me about where you live: Do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. An explicit focus on limitations may be counterproductive.
A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years?
- A. Lifelong eating habits are acquired.
- B. Peer pressure influences growth rate.
- C. BMI is determined.
- D. Culture begins begin to influence diet.
Correct Answer: A
Rationale: Adolescence is a time period of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, nutrition analysis, and intervention are critical. Peer pressure does not influence growth rate. Cultural influences tend to become less important during the teen years; they do not emerge for the first time at this age. BMI can be assessed at any age.