Question 1

As the nurse assesses the patient's neck, the patient says, "My neck is so stiff I can hardly move it." This finding indicates the nurse should perform a(n)

Accepted Answer

A)   specific examination.
B)   screening examination.
C)   focused examination.
D)   extensive examination. C

Question 2

The nurse is admitting a patient who has just arrived on the medical-surgical unit with severe abdominal pain. The action by the nurse that will be most effective in obtaining complete and accurate data from the patient is

Accepted Answer

A)   to complete only basic demographic data before addressing the patient's abdominal pain.
B)   to inform the patient that the abdominal pain will be treated as soon as the health history is completed.
C)   to take the initial vital signs and then deal with the abdominal pain prior to completing the health history.
D)   to medicate the patient for the abdominal pain before attending to the health history and examination. C

Question 3

Adaptations used by the nurse when performing a physical examination on an 86-year-old patient will include

Accepted Answer

A)   avoiding the use of touch as much as possible.
B)   organizing the sequence to minimize position changes.
C)   using slightly more pressure for palpation of the liver.
D)   speaking slowly when directing the patient. B

Question 4

When the nurse is gathering information of a personal nature, the question that best communicates acceptance of the patient is,

Accepted Answer

A)   "Individuals going through a divorce have many emotional problems. What kind of problems are you having?"
B)   "Many older people have limited financial resources for food and medications. Is this a problem in your case?"
C)   "A lot of people drink alcohol in excessive amounts. How much alcohol do you drink in a day?"
D)   "Many drugs used for hypertension cause sexual dysfunction. What type of problems are you having?"

Question 5

The nurse records the following general survey of a patient: "The patient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features." Additional information that should be added to this general survey includes

Accepted Answer

A)   reasons for contact with the health care system.
B)   comments of family members about his condition.
C)   nutritional status.
D)   intake and output.

Question 6

During the health history interview, a patient tells the nurse about periodic fainting spells. In gathering more specific information, the question that will best assist in determining the setting where the fainting spells occur is,

Accepted Answer

A)   "Do the spells tend to occur at any special time of day?"
B)   "How frequently do you have the fainting spells?"
C)   "Where are you when you have the fainting spells?"
D)   "Do you have any other symptoms along with the spells?

Question 7

A patient is seen in the emergency department with acute nausea and vomiting. The nurse obtains information about the length of time that the patient has been nauseated, the approximate amount of the emesis, and performs a physical assessment of the patient's abdomen. This will be described as a/an

Accepted Answer

A)   comprehensive database.
B)   episodic assessment.
C)   follow-up database.
D)   subjective assessment.

Question 8

A patient having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to

Accepted Answer

A)   use the health care provider's medical history to obtain subjective data.
B)   obtain subjective data about the patient from family members.
C)   delay subjective data collection and focus only on the physical examination.
D)   schedule several short sessions with the patient to gather subjective data.

Question 9

The nurse is preparing to perform a screening physical examination for a patient. The assessment technique that will require a stethoscope is

Accepted Answer

A)   inspection.
B)   percussion.
C)   auscultation.
D)   palpation.

Question 10

A patient is admitted to the orthopedic unit with a fractured right elbow following a skiing accident. During the initial nursing assessment, the subjective information the nurse obtains from the patient about how the injury occurred and what treatments have been implemented is related to the functional health pattern of

Accepted Answer

A)   activity-exercise.
B)   cognitive-perceptual
C)   health perception-health maintenance.
D)   self-perception-self-concept.

Question 11

While the nurse is taking the health history, a patient states, "My father and grandfather both had heart attacks and were unable to be very active afterwards." This statement is related to the functional health pattern of

Accepted Answer

A)   health perception-health management.
B)   activity-exercise.
C)   cognitive-perceptual.
D)   coping-stress tolerance.

Question 12

Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient's coping-stress tolerance pattern is

Accepted Answer

A)   "What do you think caused this abdominal pain?"
B)   "Are there any other major problems that are a concern right now?"
C)   "How do you feel about yourself and your hospitalization?"
D)   "Can you tell me how intense your pain is now?"

Question 13

All the following information is obtained by the nurse while performing a health history and physical examination from a patient with right-sided rib fractures. The pertinent negative finding is that the patient

Accepted Answer

A)   states that there have been no other health problems recently.
B)   refuses to take a deep breath because of the associated chest pain.
C)   has several bruised and swollen areas on the right anterior chest.
D)   denies having pain when the area over the fractures is palpated.

Question 14

Following knee surgery, the patient has an elastic bandage applied to the surgical site. When assessing the circulation to the lower leg, the first action the nurse will take is to

Accepted Answer

A)   visually inspect the color of the foot.
B)   palpate the temperature of the foot.
C)   use a stethoscope to auscultate ankle blood pressure.
D)   check the patient's pedal pulses using the fingertips.

Question 15

In performing a physical examination, it is most important for the nurse to use

Accepted Answer

A)   the head-to-toe approach.
B)   a consistent, systematic approach.
C)   the body-systems model.
D)   a model based on a nursing theory.

Exam 4: Health History and Physical Examination