N405: Week 1 Foundations of Health Assessment Chapter 3, Health History and Physical Examination

The nurse is performing a health history on the patient. Which information would the nurse document as subjective data?

"I feel nervous, nauseated, and hot." "I feel nervous, nauseated, and hot," is correct because these are symptoms that are described or verified by the patient. BP of 136/84 is objective data. This is information that is observed or measured by the health care provider. Pulses present in the lower extremities are objective data that are measured using palpation. The right lower leg being reddened and warm to the touch is objective data that is measured by observation using inspection and palpation.

At change of shift, a nurse is assigned a patient who has been on the unit for one week; however, the nurse has not cared for this patient previously. Which type of assessment is most appropriate for this scenario?

A focused assessment There are three types of assessments: comprehensive, focused, and emergency. Whereas a comprehensive assessment is a viable option, in this situation a focused assessment is most appropriate. A comprehensive assessment would already have been performed when this patient was admitted to the hospital, and the patient may be fatigued by repetitive questioning. The nurse would use a focused assessment, revising, or adding to a comprehensive assessment. In addition, to ensure that this nurse can appropriately manage time, a focused assessment would be most appropriate in this situation.

A nurse would use which technique to assess the bowel sounds of a patient?

Auscultation Auscultation is used to listen to sounds produced in the body using a stethoscope. This technique can be used to assess bowel sounds. Inspection may or may not show the presence of fluid in the abdomen. Palpation can be used to assess masses, vibrations, swelling, and tenderness. Percussion is a technique that produces a specific sound and vibration to obtain information about underlying area.

Which assessment technique is appropriate for the nurse to use when assessing the patient for bruits of the carotid artery?

Auscultation Bruits are a series of sounds that occur when blood flows through the blood vessels. These sounds are assessed by using a stethoscope; therefore the nurse should auscultate the carotid artery for assessing a bruit. Palpation involves the use of touch for assessment. Inspection involves direct observation of a body part. Percussion involves listening to hyperresonating sounds. These methods are not useful in assessing bruits.

The nurse would place assessment findings related to vision and hearing under which functional health pattern?

Cognitive-perceptual pattern 4 Health-perception-health-management pattern Assessment of the cognitive-perceptual pattern involves a description of all senses (vision, hearing, taste, touch, and smell) and the cognitive functions, with pain included as a sensory perception. Activity-rest pattern, self-perception-self-concept pattern, and health-perception-health-management pattern don't involve vision and hearing.Test-Taking Tip: A psychologic technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."

Which abnormality would the nurse assess through the technique of auscultation?

Heart Murmur Auscultation involves listening to the sounds produced by the body with the help of a stethoscope. The murmur in the heart can be heard by auscultation. Hypothermia, organ enlargement, and muscular spasms can be assessed by the technique of palpation, which involves the use of light and deep touch to yield information.

Which technique would the nurse use to examine a patient's surgical incision?

Inspection Inspection is the visual examination of a region or part of a body. Observing a particular region helps to determine if there is any alteration. A surgical wound can be examined by inspecting the wound alone. Palpation can be used to assess masses, vibrations, swelling, and tenderness. Percussion is a technique that produces a specific sound and vibration to obtain information about the underlying area. Auscultation is used to listen to sounds produced in the body using a stethoscope.

Which type of data is the nurse collecting when assessing a patient's BP, pulse, and respirations?

Objective Objective data can be observed or measured and can be obtained using inspection, palpation, percussion, and auscultation. Vital signs are a type of objective data. Primary data is not a classification of data type collected by the nurse. Subjective data is information collected during the interview and includes information that can be described or verified by the patient. The patient health history is subjective data. A medical history is data contributed by the health care provider. This is not collected by the nurse.

While interviewing a patient with a history of chronic headaches, a nurse asks, "Does cold therapy make you feel better?" The nurse is assessing which characteristic of pain?

Palliative The precipitating and palliative factor helps to determine the conditions under which the symptoms are alleviated or relieved. Therefore asking the patient whether the cold therapy helps to relieve the headache assesses the precipitating and palliative factor in the patient. The quality factor determines the type of pain, such as dull or aching. Radiation will determine whether the pain is spreading or is restricted to a specific region. Severity helps in rating the pain on a scale of 0 to 10.

Which assessment techniques would the nurse perform to obtain objective data from a patient? Select all that apply.

Palpation Inspection Diagnostic tests Objective data are the data that can be observed or measured through inspection, palpation, percussion, and auscultation. The objective data about the patient can also be obtained through diagnostic testing. Subjective data are obtained through interviews that include direct questioning and interrogation.

Which technique would the nurse use to assess texture, moisture, swelling, tenderness, and pain?

Palpation Palpation is the examination of the body using touch. The sense of touch allows the health care provider to assess texture, moisture, swelling, and tenderness and pain of a body part or region. Inspection is the visual examination of a part or region of the body to assess normal conditions or deviations. Percussion is a technique that produces a sound and vibration to obtain information about the underlying area. Auscultation is listening to sounds produced by the body using a stethoscope to assess normal conditions and deviations from normal.

Which assessment technique would the nurse use to examine a patient's musculoskeletal system?

Palpation and inspection Assessment of different body systems requires the use of different assessment techniques. While examining the musculoskeletal system, the nurse should use the techniques of inspection and palpation. Palpation should be done to assess for masses and muscle spasms. Inspection can be used to assess any visual abnormality in the bones and muscles. Percussion involves producing sound and vibration to assess the underlying area and may not be helpful in assessment of the musculoskeletal system. Auscultation helps in hearing the sounds produced by body organs such as the heart, lungs, and those in the abdomen.

Which is the appropriate method for a nurse to use when auscultating a patient's abdomen?

Use the diaphragm of the stethoscope for auscultation. Auscultation of the abdomen is useful in detecting high-pitched bowel sounds. The diaphragm of the stethoscope is sensitive in picking up high-pitched sounds of the abdomen. The bell of the stethoscope is sensitive in detecting low-pitched sounds like heart murmurs. The interface of the bell and the diaphragm is less useful for clinical assessment. Because the bowel sounds are high-pitched, the diaphragm should be held firmly on the skin during auscultation.