Chapter 21. Physical Assessment latest 2022 [100%c0mplete]

Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. A nurse wakes the patient for a focused assessment. The patient, trying to rest, tells the nurse, “I wish you would quit waking me up. Do you really need to keep bothering me?” The nurse appropriately responds: 1. “Most patients would love to get the attention that you are getting.” 2. “I understand your frustration, but this has been ordered by your physician.” 3. “It is necessary that I do a head-to-toe assessment from which I can determine whether there are any changes in your condition.” 4. “It is important to assess your blood pressure and pulse since we just started your new blood pressure medicine.” ____ 2. After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the patient’s plan of care. This decision is a result of the nurse’s 1. Ensuring that each patient receives a comprehensive health assessment. 2. Evaluating the effectiveness of nursing interventions. 3. Reviewing the organizational plan for the shift. 4. Learning that the patient may be discharged from the hospital during this shift. ____ 3. When performing a physical assessment of a patient, a nurse uses the five techniques of obtaining objective data. The technique that provides data by using the hands is 1. Palpation. 2. Auscultation. 3. Observation. 4. Olfaction. ____ 4. The patient’s blood pressure at 8:00 a.m. was 124/80 mm Hg, and now at 12:00 p.m., it is 152/94 mm Hg. The charge nurse appropriately instructs the newly hired nurse that 1. The patient’s blood pressure should be rechecked in 15 minutes. 2. Any abnormal findings should be rechecked within 8 hours. 3. Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours. 4. There is no reason to recheck the blood pressure because this pattern of elevation is typical for this patient. ____ 5. At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are 1. Subjective. 2. Measurable. 3. Reported by the patient. 4. Hidden. ____ 6. The nurse takes additional time getting to know a patient admitted for surgery because 1. The patient may not fully cooperate with the nurse otherwise. 2. It is important that the nurse be prepared to answer any questions that the family may have about the patient. 3. The nurse believes that a patient responds better if she and the patient are on a first-name basis. 4. The nurse believes that establishing rapport with a patient leads to a trusting nurse-patient