Exam (elaborations)
Chapter 20 Health History and Physical Assessment
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 20 Health History and Physical Assessment
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DAWITChapter 20: Health History and Physical Assessment
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What
action by the nurse is most appropriate?
a. Offer the patient a small pillow for under his/her head.
b. Provide a method for ensuring the patient stays warm.
c. Raise the head of the bed to about 30 degrees.
d. Ensure there is enough lighting for an adequate examination.
ANS: B
The important fact in this question is that the patient is partly undressed, and the nurse
provides a means to keep the patient warm. All answers are appropriate for any examination
but keeping the patient warm is specific to this situation.
DIF: Applying OBJ: 20.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
NOT: Concepts: Communication
2. A patient wishes to review his medical record. What response by the nurse is best?
a. ―I‘m sorry, we don‘t allow you to look at your chart.‖
b. ―Let me check to see if we can allow you to do that.‖
c. ―Yes, I can sit with you while you look at it, so you can ask questions.‖
d. ―Yes, all patients can reviNwR
eU eI
thS chGarTtB
ir N s a.t C
anO
y time they wish.‖
ANS: C
Patients have the right to look at their records. It is best if a health care provider is present to
answer any questions the patient may have or to help interpret any information found within
the record.
DIF: Applying OBJ: 20.2
TOP: Integrated Process: Communication and Documentation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
3. A clinic nurse is examining an older, confused patient on an examination table and realizes a
piece of needed equipment was left outside in the hall. What action by the nurse is best?
a. Tell the patient to lie still and go get the equipment.
b. Call for another staff member to bring the equipment.
c. Have the patient get into a chair and get the equipment.
d. Finish the rest of the exam, get the equipment, and use it.
ANS: B
NURSINGTB.COM
, DAWIT
For patient safety, some patients should never be left alone on an examination table: infants;
small children; older adults who are confused, combative, or uncooperative, and people who
are physically or chemically restrained. The nurse calls for another staff member to get the
missing equipment. Getting up and down off the table is inconvenient and may be difficult.
Finishing the exam and then retrieving the piece of equipment also involves the patient
changing locations and is inconvenient for the patient.
DIF: Applying OBJ: 20.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control NOT: Concepts: Safety, Clinical Judgment
4. A student nurse is preparing to auscultate a patient‘s lungs. What action by the student leads
the instructor to intervene?
a. Student asks to turn the television volume down.
b. Student warms the bell of the stethoscope before use.
c. Student uses the stethoscope bell to listen to bowel sounds.
d. Student places the stethoscope diaphragm on the patient‘s skin.
ANS: C
The diaphragm is used to listen to bowel sounds. The other actions are appropriate.
DIF: Applying OBJ: 20.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
NOT: Concepts: Clinical Judgment
5. The nurse is assessing a patient‘s alcohol intake. What question is most appropriate?
a. ―Do you drink alcohol at all?‖
b. ―You don‘t drink much dN yoRuS
oU ? ‖INGTB.COM
c. ―When was your last drink?‖
d. ―How much alcohol do you drink daily?‖
ANS: D
The nurse needs to be nonjudgmental when inquiring about topics that might be sensitive,
such as alcohol or drug use. The nurse asks a neutral, objective question such as ―How much
alcohol do you drink daily?‖ that allows the patient to quantify the intake. Avoid yes/no
questions because they are closed ended and do not lead to further discussion or disclosure.
Avoid a negatively charged question such as, ―You don‘t drink much, do you?‖; this
demonstrates the nurse‘s displeasure with drinking. Asking when the last drink was is not as
important in a general survey as quantifying the amount of intake.
DIF: Applying OBJ: 20.4 TOP: Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Communication
6. The nurse is planning to educate four patients on preventing skin cancer and early warning
signs. Which patient is the priority for this education?
a. Adolescent who uses a tanning bed
b. Middle-aged adult who walks for fitness
c. Older woman who sits in the sun for 10 minutes daily
d. Person who works indoors under fluorescent lights
ANS: A
NURSINGTB.COM
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