Chapter 3. Health History and Physical Examination
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Course
Medical surgical nursing
Institution
Medical Surgical Nursing
Chapter 03: Health History and Physical Examination
Lewis: Medical-Surgical Nursing in Canada,
MULTIPLE CHOICE
1. An older-adult client 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...
Chapter 03: Health History and Physical Examination
Lewis: Medical-Surgical Nursing in Canada,
MULTIPLE CHOICE
1. An older-adult client 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 client 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 client to gather subjective data.
ANS: D
In the case of an older-adult client with a low energy level, several short sessions may have to
be scheduled. Allowing time for the client to volunteer information about particular areas of
concern enables the nurse to work with the client 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 client will
be able to give subjective information about the shortness of breath. Since the subjective data
about the client’s respiratory status will be essential, obtaining the physical examination alone
will not provide sufficient information.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
NURSINGTB.COM
2. Immediate surgery is planned for a client with acute abdominal pain. Which of the following
questions will elicit the most complete information about the client’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?”
ANS: D
The coping-stress tolerance pattern includes information about other major stressors
confronting the client. The health perception–health management pattern includes information
about the client’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.
3. During the health history interview, a client 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?”
ANS: B
Information about the setting is obtained by asking where the client was and what the client
was doing when the symptom occurred. The other questions from the nurse are appropriate for
obtaining information about chronology, frequency, and associated clinical manifestations.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
4. The nurse records the following general survey of a client: “The client is a 68-year-old male
Asian accompanied by his wife and two daughters. Alert and oriented. Does not make eye
contact with the nurse and responds slowly, but appropriately, to questions. No apparent
disabilities or distinguishing features.” Which of the following information should be added to
this general survey documentation?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
ANS: A
The general survey also describes the client’s general nutritional status. The other information
will be obtained when doing the complete nursing history and examination but is not obtained
through the initial scanning of a client.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
N R I G B.C M
U S N T O
5. A nurse is performing a health history and physical examination for a client with right-sided
rib fractures. Which of the following data is a pertinent negative finding?
a. Client states that there have been no other health problems recently.
b. Client denies having pain when the area over the fractures is palpated.
c. Client has several bruised and swollen areas on the right anterior chest.
d. Client refuses to take a deep breath because of the associated chest pain.
ANS: B
The nurse expects that a client with rib fractures will have pain over the fractured area. The
first statement is neither a positive nor a negative finding with regard to the rib fractures. The
bruising and swelling and pain with breathing are positive findings.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
6. As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardly move
it.” This client statement indicates the nurse should perform which of the following
assessments?
a. Focused
b. Screening
c. Emergency
d. Comprehensive
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