Health Assessment
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| Examples of chronic pain behaviors include all of the following EXCEPT: | vomiting
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| Which of the following conditions is an example of visceral pain? | Cholecystitis
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| When assessing a 75 year old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse would: | recognize that a tripod position is often used when a patient is having respiratory difficulties.
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| The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: | use a Doppler device to check for pulsations over the area.
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| Which of the following statements is true regarding use of the tympanic thermometer? | There is a reduced risk of cross-contamination when compared to the rectal route.
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| A patient is at the clinic for a physical examination and states that they are "very anxious" about the exam. What steps can the nurse take to make them more comfortable? | appear unhurried and confident when examining them.
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| You are assessing the vital signs of a 20-year-old marathon runner. You document the following vital signs: temperature - 97 degrees F; pulse - 48 BMP; respirations - 14/minute; blood pressure - 104/68. Which of the following statements is true? | These are normal vital signs for a healthy, athletic adult.
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| While auscultating heart sounds, the nurse hears a murmur. Which of the following should be used to assess this murmur? | the bell of the stethoscope
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| Which of the following statements is true regarding the otoscope? | The otoscope directs light into the ear canal and onto the tympanic membrane
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| When would you use a bi-manual palpation technique? | Palpating the kidneys and uterus
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| Which question would best identify factors which alleviate or aggravate pain? | What makes your pain better or worse?
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| A patient's blood pressure is obtained at 140/95. This falls into which of the blood pressure classifications? | Stage I hypertension
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| A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? | Administer pain medication and then proceed with the assessment.
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| Which of the following vital sign changes occur with aging? | inspection
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| During the examination, it is often appropriate to offer some brief teaching about the patient's body or one's findings. Which of the following statements by the nurse is most appropriate? | "Your pulse is 80 beats per minute. This is within the normal range."
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| Your patient's blood pressure is 118/82. He asks you to explain "what the numbers mean." You reply: | "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts."
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| When measuring a patient's weight: | attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
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| In assessing the radial pulse of a patient, you would: | takes time and reveals a surprising amount of information.
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| Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? | Palpation
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| An infection acquired during hospitalization is called a/an _________ infection. Question 22 answers | nosocomial
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| Select the best description of an accurate assessment of a patient's respirations. | Count for 30 seconds following pulse assessment.
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| Your patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 0 to 10 scale. Which of the following objective assessment findings indicates an acute pain response to poorly controlled pain? | Increased blood pressure and pulse
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| Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse will: Question 26 answers | check the temperature of the room and offer blankets to the patient if he or she feels cold.
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| Which of the following statements is true regarding the use of standard precautions in the health care setting? | Standard precautions are intended for use with all patients regardless of their risk or presumed infection status.
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| After inspecting and auscultating the abdomen, you are preparing to assess your patient's abdomen by palpation. How should you proceed? | Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
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| When examining the aging adult you should: | arrange the sequence to allow as few position changes as possible.
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| A 70-year-old male has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. Interpret these findings: | The change in blood pressure readings is called orthostatic hypotension.
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| You are examining a patient's lower leg and note a draining ulceration. Which of the following actions is most appropriate in this situation? | Wash your hands, put on gloves, and continue with the examination of the ulceration.
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| A patient is late for his appointment and has rushed to your clinic to have his vital signs assessed. Your first step should be to: | allow him time to relax and rest 5 minutes before checking his vital signs.
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| Which statement indicates that the health care giver understands the pain experience in the elderly? | "Pain indicates pathology or injury and is not a normal process of aging."
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| The purpose of percussion is to assess the underlying: | tissue density.
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| A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should you proceed with the examination? | Record his blood pressure in the lying, sitting, and standing positions.
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| When assessing the quality of a patient's pain, the nurse should ask which question? | "What does your pain feel like?"
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| You have collected the following information on a patient: auscultated BP - 170/100; radial pulse - 80. What is the patient's pulse pressure? | 70
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| Which of the following is considered the most reliable indicator of pain? | The subjective report
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| The pulse pressure is obtained by: | subtracting the diastolic pressure from the systolic pressure.
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| Pain that is felt at a particular site but originates from another location is called: | referred pain.
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| When performing a physical examination, safety must be considered to protect you and the patient against the spread of infection. Which of the following statements describes the most appropriate actions to be taken when performing a physical examination? | Wash your hands at the beginning of the examination and any time that you leave and re-enter the room.
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| After assessing the patient's pulse, the nurse determines it to be "normal". This would be documented as: | 2+
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| Various parts of the hands are used during palpation. The part of the hand used for the assessment of vibrations is the: | ulnar surface of the hand.
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| You are preparing to check the blood pressure of an obese patient using a standard-sized blood pressure cuff. You would expect the reading to: | yield a falsely high blood pressure.
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| Which of the following statements is true about the axillary route for temperatures? | The axillary route is safer and more accessible than the rectal route.
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| At what phase during nocieption does the individual become aware of a painful sensation? | perception
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| When counting an infant's respirations, the nurse will: Question 47 answers | watch the abdomen for movement.
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| When evaluating a patient's pain, the nurse knows that an example of acute pain would be: | kidney stones
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| You are preparing to assess a hospitalized patient who is experiencing severe shortness of breath. How should you proceed with the assessment? | Examine body areas appropriate to the problem, then complete the full assessment after the acute problem has resolved.
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| Which of the following describes the correct technique to use when assessing oral temperature with a mercury thermometer? | Leave the thermometer in place up to 8 minutes if febrile.
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