Exam 20: Health History and Physical Assessment

A nurse is assessing a patient's abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?

A nurse is educating women on breast cancer risk reduction. What topics does the nurse include in the presentation?

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 nurse assesses a patient's lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best?

A nurse has conducted an Allen's test on a patient and the result was 8 seconds. What action by the nurse is best?

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 nurse is conducting a physical examination using palpation. Which assessments might the nurse note?

A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process?

A nurse is assessing a patient's cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best?

The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate?

A student nurse is preparing to auscultate a patient's lungs. What action by the student leads the instructor to intervene?

A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best?

The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best?

The nurse is assessing a patient's cranial nerve III. What technique is best?

A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best?

A patient wishes to review his medical record. What response by the nurse is best?

A nurse has assessed a patient's capillary refill, which was 5 seconds. What action by the nurse is most appropriate?

A nurse is told in hand-off report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient's Glasgow Coma Scale to be?

The nurse is assessing a patient's alcohol intake. What question is most appropriate?

A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate?