Health Assessment Exam 1

A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission?

A comprehensive assessment

Which situation illustrates a screening assessment?

A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels.

The nurse is caring for a patient with a femur fracture. An immobilization device is used to maintain the alignment of the femur. The nurse palpates the top of the foot to make which determination?

Adequacy of blood perfusion to the foot

Because a nurse seeks to create a patient-centered interview process, the nurse will:

Ask the patient, "Can you please tell me more about your spells?"

Auscultation is a component of which examination technique?

Blood pressure measurement

Preparation for an interview with a patient requires thoughtful consideration of the physical environment. As the physical space is arranged:

Desks are usable as long as they are not a barrier between interviewer and interviewee.

Collection of objective data from a patient with a swollen left elbow includes which piece of equipment?

Goniometer

Which infection control intervention is most frequently applied?

Hand hygiene

Health histories can provide nurses with data needed for appropriate care. Nurses obtaining a health history should:

Help the patient identify personal beliefs about health.

The nurse records the following general inspection findings on a patient: "41-year-old Hispanic male in no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than his stated age. Patient with flat affect and makes minimal eye contact" What additional information should be added to this general inspection?

His body movement

A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse needs to ensure that:

Information about the patient's lifestyle habits is gathered.

While examining a patient with an infected abdominal incision, the nurse notices that it is very malodorous. Which technique does this represent?

Inspection

Which assessment data are determined by the use of a goniometer?

Measurement of joint flexion

The nurse is preparing the room for the dermatologist. The nurse knows that the patient may have a fungal infection on the left leg. Which tool is not part of the setup for this assessment?

Monofilament

After collecting data, the nurse begins data analysis with which activity?

Organizing the data collected

A 62-year-old patient tells the nurse that he has recently had frequent fainting spells. After palpating the radial pulse, 13 pulsations are counted in 15 seconds with a regularly irregular rhythm. What is the most appropriate action for the nurse to take at this time?

Palpate the pulse for one minute and determine the pattern to the irregularity.

The nurse is working in a primary care clinic. She walks into the room, and the general inspection begins. What is not part of the general inspection?

Patient is wearing clothes that are normally worn by Whites.

The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that:

Rectal thermometers are placed 2.5 cm to 3.8 cm into the rectum.

A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of:

Secondary prevention

Select the example given below that represents information a nurse collects from a patient during a physical examination.

Shiny skin and lack of hair found on lower legs

The nurse obtains vital signs on a 42-year-old man having his annual physical exam. He has no medical conditions and states that his health is excellent. Using an automated blood pressure device, his blood pressure is measured as 62/40. Which action by the nurse is most appropriate?

Take the blood pressure again using the auscultation method.

A patient is brought to the emergency department in severe respiratory distress. Which method of temperature measurement would be the most appropriate?

Temporal artery

The nurse documents which information in the patient's history?

The patient reports itching of her eyes.

A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need to assess her blood pressure. The nurse explains to the patient that:

Using a cuff that is too narrow will give a reading that is inaccurate and high.