lOMoAR cPSD| 11700591
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,Chapter 1
MULTIPLE CHOICE
1. For which of the following patients would a comprehensive health history be appropriate?
A) A new patient with the chief complaint of ―I sprained my ankle‖
B) An established patient with the chief complaint of ―I have an upper respiratory infection‖
C) A new patient with the chief complaint of ―I am here to establish care‖
D) A new patient with the chief complaint of ―I cut my hand‖
Answer: C
Chapter: 01
Page and Header: 4, Patient Assessment: Comprehensive or Focused
Feedback: This patient is here to establish care, and because she is new to you, a comprehensive
health history is appropriate.
2. The components of the health history include all of the following except which one?
A) Review of systems
B) Thorax and lungs
C) Present illness
D) Personal and social items
Answer: B
Chapter: 01
Feedback: The thorax and lungs are part of the physical examination, not part of the health
history. The others answers are all part of a complete health history.
3. Is the following information subjective or objective?
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity
and relieved by rest.
A) Subjective
B) Objective
Answer: A
Chapter: 01
4. Is the following information subjective or objective?
Mr. M. has a respiratory rate of 32 and a pulse rate of 120.
A) Subjective
B) Objective
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
Answer:
Ans: A B
Chapter: 01
Chapter: 01
Feedback: This
Feedback: This is
is information
a measurement obtained
about by the hospitalization
a significant examiner, so it and
is considered
should beobjective
placed indata.
the
The patient is unlikely to be able to give this information to the examiner.
adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
5. The following information is recorded in the health history: ―The patient has had abdominal
pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9
on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-
epigastric area.‖
Which of these categories does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Answer: B
Chapter: 01
Feedback: This information describes the problem of abdominal pain, which is the present
illness. The interviewer has obtained the location, timing, severity, and associated manifestations
of the pain. The interviewer will still need to obtain information concerning the quality of the
pain, the setting in which it occurred, and the factors that aggravate and alleviate the pain. You
will notice that it does include portions of the pertinent review of systems, but because it relates
directly to the complaint, it is included in the history of present illness.
6. The following information is recorded in the health history: ―The patient completed 8th grade.
He currently lives with his wife and two children. He works on old cars on the weekend. He
works in a glass factory during the week.‖
Answer: C
Chapter: 01
Feedback: Personal and social history information includes educational level, family of origin,
current household status, personal interests, employment, religious beliefs, military history, and
lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual
preferences and history). All of this information is documented in this example.
7. The following information is recorded in the health history: ―I feel really tired.‖
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
Answer: A
Chapter:
Ans: A 01
Chapter: 01
Feedback: The chief complaint is an attempt to quote the patient's own words, as long as they
are suitableThis
Feedback: to print. It is brief, about
is information like a headline, andhospitalization
a significant further details should be sought
and should in the
be placed inpresent
the
illness section. The above information is a chief complaint.
adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
8. The following information is recorded in the health history: ―Patient denies chest pain,
palpitations, orthopnea, and paroxysmal nocturnal dyspnea.‖
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Answer: D
Chapter: 01
Feedback: Review of systems documents the presence or absence of common symptoms related
9. The following information is best placed in which category?
―The patient has had three cesarean sections.‖
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Answer: B
Chapter: 01
Feedback: A cesarean section is a surgical procedure. Approximate dates or the age of the patient
at the time of the surgery should also be recorded.
10. The following information is best placed in which category?
―The patient had a stent placed in the left anterior descending artery (LAD) in 1999.‖
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Answer: A
Chapter: 01
Feedback: The adult illnesses category is reserved for chronic illnesses, significant
hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but
does not involve a surgeon.
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
Ans: A
11. The following information is best placed in which category?
Chapter: 01
―The patient was treated for an asthma exacerbation in the hospital last year; the patient has
never been intubated.‖
Feedback: This is information about a significant hospitalization and should be placed in the
A) Adult illnesses
adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
placing this information in the present illness section, because it relates to the chief complaint at
that visit.
Chapter 2 Critical Thinking in Health Assessment
MULTIPLE CHOICE
1. When performing a physical assessment, the first technique the nurse will always use is:
a. Palpation.
b. Inspection.
c. Percussion.
d. Auscultation.
ANSWER: B
The skills requisite for the physical examination are inspection, palpation, percussion, and
auscultation. The skills are performed one at a time and in this order (with the exception of the
abdominal assessment, during which auscultation takes place before palpation and percussion).
The assessment of each body system begins with inspection. A focused inspection takes time and
yields a surprising amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about the
physical assessment? The inspection phase:
a. Usually yields little information.
b. Takes time and reveals a surprising amount of information.
c. May be somewhat uncomfortable for the expert practitioner.
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
a. Turgor
b. Texture
c. Density
A focused inspection takes time and yields a surprising amount of information. Initially, the
examiner may feel uncomfortable, staring at the person without also doing something. A focused
assessment is significantly more than a quick glance.
3. The nurse is assessing a patients skin during an office visit. What part of the hand and
technique should be used to best assess the patients skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances
temperature sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature
variations because of its increased nerve supply in this area.
ANSWER: B
The dorsa (backs) of the hands and fingers are best for determining temperature because the skin
is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile
discrimination. The other responses are not useful for palpation.
4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and
swelling when the nurse is assessing a patient?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
ANSWER: A
5. The nurse is preparing to assess a patients abdomen by palpation. How should the nurse
proceed?
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
a. Turgor
b. Texture
c. Density
a. Palpation of reportedly tender areas are avoided because palpation in these areas
may cause pain.
b. Palpating a tender area is quickly performed to avoid any discomfort that the
patient may experience.
c. The assessment begins with deep palpation, while encouraging the patient to relax
and to take deep breaths.
d. The assessment begins with light palpation to detect surface characteristics and to
accustom the patient to being touched.
ANSWER: D
Light palpation is initially performed to detect any surface characteristics and to accustom the
person to being touched. Tender areas should be palpated last, not first.
6. The nurse would use bimanual palpation technique in which situation?
a. Palpating the thorax of an infant
b. Palpating the kidneys and uterus
c. Assessing pulsations and vibrations
d. Assessing the presence of tenderness and pain
ANSWER: B
Bimanual palpation requires the use of both hands to envelop or capture certain body parts or
organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for
bimanual palpation.
7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to
assess the of the underlying tissue.
d. Consistency
ANSWER: C
Percussion yields a sound that depicts the location, size, and density of the underlying organ.
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
a. Turgor
b. Texture
c. Density
Turgor and texture are assessed with palpation.
8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique,
if used by the new nurse, indicates that more review is needed?
a. Percussing once over each area
b. Quickly lifting the striking finger after each stroke
c. Striking with the fingertip, not the finger pad
d. Using the wrist to make the strikes, not the arm
ANSWER: A
For percussion, the nurse should percuss two times over each location. The striking finger should
be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger
should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the
strikes, not the arm.
9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
a. Consider this a normal finding.
b. Palpate this area for an underlying mass.
c. Reposition the hands, and attempt to percuss in this area again.
d. Consider this finding as abnormal, and refer the patient for additional treatment.
ANSWER: A
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Bates' Nursing Guide to Physical Examination and History Taking / Edition 3 Testbank
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound.
The other responses are not correct.
10. The nurse is unable to identify any changes in sound when percussing over the abdomen of
an obese patient. What should the nurse do next?
a. Ask the patient to take deep breaths to relax the abdominal musculature.
b. Consider this finding as normal, and proceed with the abdominal assessment.
c. Increase the amount of strength used when attempting to percuss over the
abdomen.
d. Decrease the amount of strength used when attempting to percuss over the
abdomen.
ANSWER: C
The thickness of the persons body wall will be a factor. The nurse needs a stronger percussion
stroke for persons with obese or very muscular body walls. The force of the blow determines the
loudness of the note. The other actions are not correct.
11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-
year-old child. The nurse should:
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths, and percuss over the area again.
c. Immediately refer the child because of an increased amount of air in the lungs.
d. Consider this finding as normal for a child this age, and proceed with the
examination.
ANSWER: D
Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in
duration are normal over a childs lung.
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