Ch. 3 Health History and Examination

The nurse is performing a health history on the patient. Which information will the nurse document as subjective data? 1 Blood pressure is 136/84. 2 "I feel nervous, nauseated, and hot." 3 Pulses present in lower extremities. 4 Right lower leg is reddened and warm to palpation

"I feel nervous, nauseated, and hot" is correct because these are symptoms that are described or verified by the patient. Blood pressure is 136/84 is objective data. This is information that is observed or measured by the health care provider. Pulses present in lower extremities is objective data that is measured using palpation. Right lower leg is reddened and warm to touch is objective data that is measured by observation using inspection and palpation. Text Reference - p. 38

The nurse is conducting an interview with a patient. Which response made by the nurse is most therapeutic? 1 "I need information from you if you have some time to talk." 2 "It is really cold out today, isn't it? So how are you doing today?" 3 "I would like to ask you a few questions about what brought you here." 4 "I would like to ask your family questions about what brought you here."

"I would like to ask you a few questions about what brought you here" is correct because the nurse needs to communicate acceptance of the patient by using an open, responsive, nonjudgmental approach. "I need information from you if you have some time to talk" does not open the patient up to talking about his or her problems and does not promote a trusting relationship. "It is really cold out today, isn't it? So how are you doing today?" does not show that the health care provider is interested in the patient and does not indicate trust and respect. "I would like to ask your family questions about what brought you here" is incorrect because it is important for the nurse to determine the patient's priority concerns and expectations. It is important to communicate an acceptance of the patient as an individual by using an open responsive nonjudgmental approach. Creating a climate of trust and respect is critical to building a trusting relationship. Text Reference - p. 38 TEST-TAKING TIP: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

A patient has chronic renal failure. During the assessment, the nurse makes note that there is pitting edema on one leg and that the texture of the skin overlying the edema has changed. Also, the temperature of the edematous area has increased. Which techniques of assessment has the nurse used to arrive at these findings? Select all that apply. 1 Palpation 2 Inspection 3 Percussion 4 Auscultation 5 Interrogation

1, 2 The pitting nature of the edema can be confirmed by palpation. The edema can also be observed by inspection. The change in texture of the skin can be observed by inspection and palpation. An increase in the temperature can be felt by palpation. Percussion involves producing sound and vibration to yield information; therefore, edema cannot be assessed through percussion. Auscultation involves listening to the sounds in the body using a stethoscope; this technique of assessment does not help in assessing edema. Interrogation helps in collecting a patient's related history, and does not contribute to the assessment of edema. Text Reference - p. 42

A nurse is providing care for a patient with narcolepsy. Which interventions should be included on the patient's treatment plan? Select all that apply. 1 Advise abstaining from alcohol consumption. 2 Provide education about sleep and sleep hygiene. 3 Encourage heavy meals before taking short naps. 4 Encourage taking 3 or more short naps during the day. 5 Convince the patient that the condition can be cured with drug therapy.

1, 2, 4 A decreased level of orexin or its receptors, which leads to difficulties staying awake, is called narcolepsy. Those suffering from narcolepsy should not take any substance that reduces alertness during the day, especially alcohol. These patients should be trained about sleep and sleep hygiene techniques to promote sleep. These patients should be encouraged to take 3 or more short naps during day to promote alertness. Heavy meals should be discouraged, because they may make the individuals drowsy. As of now there are no drugs that can cure the disease, but there are drugs that increase alertness during the day. Text Reference - p. 105

A nurse is performing a physical assessment on an older patient. What adaptations should the nurse make to ensure patient comfort? Select all that apply. 1 Provide a quiet environment free from distractions. 2 Change the position frequently. 3 Handle the skin with care. 4 Have the patient perform deep knee bends. 5 Use caution in palpating the liver.

1, 3, 5 Adaptations of the physical examination helps with assessment of older patients who may have age-related problems. The environment should be quiet as noise may distract the sensory-impaired patient. The skin is very fragile and should be handled with care. The skin is very thin, so the liver is easily accessible for palpation. The nurse should avoid putting pressure when palpating the liver. The position should not be changed frequently as it can cause discomfort. The patient should not be asked to perform deep kneed bends due to a likely limited range of motion. Text Reference - p. 45

An 89-year-old patient has arthritis with inflamed joints. When performing the patient's physical assessment, what adaptations should the nurse make? Select all that apply. 1 Avoid having patient hop on one foot. 2 Ask the patient to perform deep knee bends. 3 Provide gentle movements and reinforcement techniques. 4 Ask the patient to stand and bend to examine joint flexibility. 5 Perform the general examination in a comfortable position.

1, 3, 5 Considering the age and joint inflammation of the patient, certain changes need to be done in the physical assessment technique. It is important to avoid having the patient hop on one foot as it may worsen the patient's condition. Also, it is necessary to provide gentle movements and reinforcement techniques to ensure comfort. The assessment should be performed in a comfortable position to yield accurate results. Deep knee bends should be avoided to prevent the condition from aggravating. It is important to avoid unnecessary activities or changes in position as the patient suffers from arthritis and it may be painful. Text Reference - p. 45

By using the technique of palpation, the nurse can obtain what information about a patient's thorax? 1 Retraction of the nipples 2 Enlarged lymph nodes 3 Presence of apical impulse 4 Bruits at carotid artery

2 Palpation is the examination of the body using touch. It can yield information related to organ enlargement, tenderness, pain, or swelling. Therefore, enlargement of lymph nodes can be determined by palpation. Retraction of nipples and the presence of apical impulse can be determined by inspection, and bruits at carotid artery can be heard by auscultation. Text Reference - p. 42

While interviewing a patient with a history of chronic headache, a nurse asks, "Does the cold therapy make you feel better?" The nurse is assessing which characteristic of pain? 1 Palliative 2 Quality 3 Radiation 4 Severity

2 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 0-10. Text Reference - p. 39

When performing a nursing history and physical assessment on an 85-year-old woman, which consideration should the nurse take into account because of this patient's age? 1 Ask the patient to exhale forcefully and inhale gently. 2 Because of the loss of subcutaneous fat, the patient's room should be kept warm. 3 Because of the increase of subcutaneous fat, the patient's skin may be fragile and tender. 4 Because of the increase in subcutaneous fat, the abdominal organs may be difficult to palpate.

2 When conducting a physical assessment on a geriatric patient, the nurse should attend to some special considerations. There is a decrease in subcutaneous fat, which makes it more difficult for the older adult to maintain an adequate skin temperature. Keeping the room warm will make the older adult comfortable during the physical examination. There is not an increase in subcutaneous fat. Often there is a decreased forced expiration in older adults. Asking them to exhale forcefully may only instigate coughing. TEST-TAKING TIP: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet). Text Reference - p. 39

An elderly patient reports pain in the abdomen. When performing palpation of the liver on the patient, the nurse exercises caution by palpating lightly. What is the primary reason for the nurse exercising caution with this patient? 1 The patient has liver enlargement. 2 The patient bruises easily. 3 The patient has a thin and soft abdominal wall. 4 The patient has exaggerated pain perception.

3 Elderly patients usually have a thinner and softer abdominal wall, which makes the abdominal organs readily accessible to palpation. Therefore, the nurse should use precaution when palpating the liver to prevent any injury. Patients with liver enlargement may need careful palpation of the abdomen; however, the enlargement is not the likely reason for pain in this patient and this is not the primary reason to palpate carefully. The skin of elderly patients does bruise more easily than that of younger patients, but that is not the primary reason for careful palpation of the abdomen. Elderly patients usually have diminished pain perception, which may prevent them from feeling pain when deep palpations are performed. Text Reference - p. 44

A patient presents to the emergency department and reports abdominal pain radiating to the back that started 2 days ago. After completing an investigation of these symptoms, the nurse will begin an abdominal examination. Drag and drop the steps of the abdominal examination into their proper order. 1. Palpate the abdomen for masses or hepatomegaly. 2. Percuss the abdomen, locating the spleen and liver. 3. Auscultate the abdomen for the presence of bowel sounds and bruits. 4. Inspect the abdomen for masses, lesions, redness, discolorations, or abnormalities.

4, 3, 2, 1 Inspection is routinely performed first for all system-specific examinations. Auscultation is performed as the second step on an examination of the abdomen. This is because percussion and palpation can stimulate the bowel and create the presence of bowel sounds, when bowel sounds would have been absent. It is important to get accurate information to make informed health care decisions. Text Reference - p. 42

A patient reports abdominal pain, vomiting, and diarrhea. The nurse determines that the patient's focused assessment should involve which body system? 1 Cardiac system 2 Gastrointestinal system 3 Respiratory system 4 Musculoskeletal system

Abdominal pain, vomiting, and diarrhea are usually seen in gastrointestinal disorders. Most of the components of this system are localized in the abdominal region; therefore, the focused assessment should be performed on the abdomen. If the patient has complaints of cough, chest pain, palpitations, and breathlessness, then the focused assessment would involve the cardiac and respiratory system. Even though musculoskeletal system diseases may be present with abdominal pain, they are not associated with vomiting and diarrhea. Text Reference - p. 43

A nurse is performing a physical examination of a patient. How should the nurse examine the musculoskeletal system? 1 Perform percussion and auscultation. 2 Perform auscultation and palpation. 3 Perform palpation and inspection. 4 Perform inspection and percussion

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 abdomen. Text Reference - p. 41

A nurse works in an acute care unit. Which abnormality can be assessed through the technique of auscultation? 1 Heart murmur 2 Hypothermia 3 Organ enlargement 4 Muscular spasm

Auscultation helps to listen 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. Text Reference - p. 42

A nurse assesses that a patient has wheezes in the apex of one lung. Which technique of physical assessment did the nurse use to make this determination? 1 Inspection 2 Palpation 3 Percussion 4 Auscultation

Auscultation is a technique in which a stethoscope is used to hear the sounds produced in the body. Wheezes produced at the apex of the right lung can be heard by auscultation. Inspection involves visual examination of a part or an area to determine any abnormalities. Palpation involves examination of the body using touch. Percussion involves producing sound and vibration to obtain information about an underlying area of the body. Text Reference - p. 42

A patient has constipation. During physical examination, the nurse auscultates the abdomen. Which is the most appropriate method for performing auscultation? 1 Use the bell of the stethoscope for auscultation. 2 Use the diaphragm of the stethoscope for auscultation. 3 Use the interface of the diaphragm and the bell for auscultation. 4 Hold the diaphragm lightly on the skin of the abdomen.

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. As the bowel sounds are high-pitched, the diaphragm should be held firmly on the skin during auscultation. Text Reference - p. 42

A nurse is performing a physical examination of a patient. Which assessment technique is appropriate for assessing bruits of the carotid artery? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

Bruits are a series of sounds which 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 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. Text Reference - p. 44

A nurse is reviewing the history reports of a patient. One of the reports reads, "Crackles in the apex of the left lung." Which technique of physical assessment would yield this result? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

Crepitations in the apex of the left lung can be heard by using a stethoscope. This technique of hearing sounds produced in the body using a stethoscope is called auscultation. Palpation can be used to assess masses, vibrations, swelling, and tenderness. Inspection involves visual examination of the body part to determine abnormalities. Percussion is a technique that produces a specific sound and vibration to obtain information about the underlying area. Text Reference - p. 42

During a physical examination, the nurse palpates the abdomen of the patient. What part of the hand should the nurse use when performing the palpation? 1 Finger tips 2 Palm proper 3 Base of fingers 4 Dorsa of hands

Finger tips are used when palpating the abdomen. It can provide information about presence of masses, pulsations, enlargement of organs, and tenderness. The palm proper is quite insensitive for assessing physical findings in a patient. The base of fingers of the palmar surface is sensitive for analyzing vibration sense. The dorsa of the hands are sensitive for assessing temperature. Text Reference - p. 41

A patient admitted to the hospital with a fever, cold, and cough has been diagnosed with tuberculosis. Which assessment should the nurse perform after the diagnosis has been made? 1 General survey 2 Emergency assessment 3 Focused assessment 4 Comprehensive assessment

Focused assessment is a brief but specific assessment that focuses on the body system that is the focus of care. It includes an assessment related to a specific problem, and monitors for signs of new problems. General assessment is a nonspecific assessment. Emergency assessment involves rapid examination and specific questioning of the patient. Comprehensive assessment involves detailed assessment of the body systems and includes a head-to-toe examination. Text Reference - p. 46

A nurse is caring for a postoperative patient who has a surgical incision. Which technique should be used to examine the surgical wound? 1 Inspection 2 Palpation 3 Percussion 4 Auscultation

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. Text Reference - p. 41

After performing a complete health history and physical examination on a patient, the nurse records the findings in the chart. Which of these is an example of an objective finding that the nurse would record? 1 The patient is currently taking labetalol 200 mg bid. 2 The patient has no known allergies. 3 The patient's pulse is 98 and the heart rate is regular. 4 The patient states: "I feel weak and fatigued."

Objective data are data that the nurse has directly observed or inspected on physical examination, such as vital signs. A pulse of 98 and a heart rate that is regular are examples of objective data. Subjective data are data that the nurse has received directly from the patient, such as a list of current prescriptions or any allergies. The patient's statement of "I feel weak and fatigued" is an example of subjective data. Text Reference - p. 38

During an admission history and physical assessment, the patient describes symptoms to the nurse. What type of data should these descriptions be documented as? 1 Objective 2 Subjective 3 Generalized 4 Comprehensive

Subjective data are collected by interviewing the patient and including information that only can be described or verified by the patient. Objective data, or signs, are data that can be observed or measured. Although generalized data is not a terminology used in nursing, a general survey will be an observation of the general state of health of the patient. Comprehensive data could be accumulated in a comprehensive assessment which includes a detailed health history and physical examination of one body system or many body systems. Text Reference - p. 37

A 10-year-old boy presents to the outpatient clinic after falling from a tree. This patient reports pain in his leg that radiates up to his knee. The nurse is concerned that the patient has fractured the distal portion of his fibula. Which question is best when conducting a symptom investigation of pain in this patient's leg? 1 What is your name and address? 2 Was anyone with you when you fell? 3 Is there anything that makes the pain worse or better? 4 Have you ever sustained an injury before on this same leg?

The best choice is asking the patient if there is anything that alleviates or aggravates the symptom. The nurse should remember the pneumonic PQRST: (P) Precipitative/Palliative, (Q) Quality, (R) Radiating, (S) Severity, (T) Timing. This pneumonic is helpful in obtaining more information from patients about specific symptoms they are feeling. Asking the patient if anything makes it worse or better is an example of (P) Precipitating/Palliative. Other questions may aid the nurse in gaining valuable information, but they are not symptom-specific. TEST-TAKING TIP: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best. Text Reference - p. 39

The nurse is performing a physical examination and is preparing to examine a patient's abdomen. Which of these reflects the proper order of the steps of an abdominal assessment? 1 Auscultation, percussion, palpation, inspection 2 Percussion, palpation, inspection, auscultation 3 Inspection, auscultation, percussion, palpation 4 Palpation, percussion, inspection, auscultation

The proper order for abdominal assessment is: inspection, auscultation, percussion, and palpation. Performing percussion and palpation before auscultation can alter bowel sounds and produce false findings. Text Reference - p. 41

The nurse is preparing to perform an assessment. Which of these statements about the nursing assessment is true? 1 The purpose is to diagnose a medical problem. 2 Assessment is performed continually throughout all phases of the nursing process. 3 The nursing assessment is limited to performing a physical examination. 4 The nurse may delegate the health history to an unlicensed assistive personnel.

The purpose of the nursing assessment is to enable the nurse to make clinical judgments or diagnoses about the patient's health status. Assessment is identified as the first step of the nursing process, but it is performed continually throughout the nursing process to validate nursing diagnoses (not to diagnose a medical problem), evaluate nursing interventions, and determine whether patient outcomes and goals have been met. The nursing assessment consists of the health history and the physical assessment. The nursing assessment may not be delegated to unlicensed assistive personnel. Text Reference - p. 36

An 80-year-old patient is undergoing a physical examination. What measures should the nurse implement to keep the patient comfortable during the examination? Select all that apply. 1 Keep the patient in a cool environment. 2 Avoid unnecessary changes in position. 3 Take appropriate care when handling the skin. 4 Perform as many exam activities as possible in the patient's comfort position. 5 Encourage the patient to perform deep knee bends

While examining an elderly patient, the nurse should avoid unnecessary changes in the position of the patient due to the limited range of motion of the extremities. The skin of the elder patient is fragile; therefore, it should be handled with care. As many tests as possible should be carried out in a comfortable position because repeated changes in position may be uncomfortable. Elderly patients have to be kept warm because they have less subcutaneous fat, which decreases their ability to keep their body warm. The patient should not be asked to perform deep knee bends due to decreased reflexes and diminished sense of balance. Text Reference - p. 44