Chapter 30 Health Assessment and Physical Examination-Fundamentals of Nursing

Chapter 30: Health Assessment and Physical Examination
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MULTIPLE CHOICE ra




1. A nursing attendant is a preceptor for a nursing attendant who just graduated from nursi
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n
g school. When caring for a hospital client , the new graduate nursing attendant begins to
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explain to the hospital client the purpose of completing a physical assessment. Which sta
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tement made by the new graduate nursing attendant requires the preceptor to intervene?
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a. ―I will use the information from my assessment to figure out if your an ra ar ra ra ra ar ar ra ra ra ra ra ar




tihypertensive medication is working effectively.‖ ra ra ra ra




b. ―Nursing assessment data are used only to provide information about the ra ra ra ra ra ar ra ra ra ra ar



effectiveness of your medical care.‖ ra ra ra ra




c. ―Nursing attendant s use data from their hospital client ’s physical assessment to ra ra ra ra ra ar ra ra ra ra ar ra ar



determine a hospital client ’s educational needs.‖ ra ra ra ra ra ra




d. ―Information gained from physical assessment helps nursing attendant s bette ra ra ra ra ra ra ra ra ra



r understand their hospital client s’ emotional needs.‖
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ACCURATE ar



ANSWER:-B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a hospital clie
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nt ’s care, not just the hospital client ’s medical care. Assessment data help to evaluate the effec
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tiveness of medications and to determine a hospital client ’s health care needs, including the ne
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ed for hospital client education. Nursing attendant s also use assessment data to identify ho
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spital client s’ psychosocial and cultural needs.
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DIF:Analyze (analysis) ra



OBJ:Discuss the purposes of physical assessment. ra ra ra ra ra ar



TOP:Communication and Documentation ra ra MSC: Management of Care ra ra ra




2. Having misplaced a stethoscope, a nursing attendant borrows a colleague’s stethoscope.
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The ra



nursing attendant next enters the hospital client ’s room and identifies self, washes hands
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wit
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h soap, and states the purpose of the visit. The nursing attendant performs proper identifi
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cati
on of the hospital client before auscultating the hospital client ’s lungs. Which critical he
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alth assessment step should the nursing attendant have performed?
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Running warm water over stethoscope ra ra ra ra




b. Draping stethoscope around the neck ra ra ra ra




c. Rubbing stethoscope with betadine ra ra ra




d. Cleaning stethoscope with alcohol ra ra ra




ACCURATE ANSWER:-D ra



Bacteria and viruses can be transferred from hospital client to hospital client when a stethosc
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ope that is not clean is used. The stethoscope should be cleaned before use on each hospital cl
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ient with isopropyl alcohol benzalkonium, or sodium hypochlorite. Running water over the ste
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, thoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damag
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e the equipment. Draping the stethoscope around the neck is not advised.
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DIF:Apply (application) ra



OBJ:Plan environmental preparations before an examination.ra ra ra ra ra



TOP:Evaluation ar



MSC: Reduction of Risk Potential ra ra ra ra




3. A nursing attendant is preparing to perform a complete physical examination on a fragile,
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olderadult hospital client diagnosed with bilateral basilar pneumonia. Which position wi
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ll th e nursing attendant use to facilitate the hospital client ’s breathing? a. Prone
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b. Sims’
c. Supine
d. Lateral recumbent ra




ACCURATE ANSWER:-C ra



Supine is the most normally relaxed position. If the hospital client becomes short of breath ea
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sily, raise the head of the bed. Supine position would be easiest for a weak, olderadult person dur
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ing the examination. Lateral recumbent and prone positions cause respirator
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y difficulty for any hospital client with respiratory difficulties. Sims’ position is used for asses
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sment of the rectum and the vagina. ra ra ra ra ra ra




DIF:Apply (application) ra



OBJ:List techniques for preparing a hospital client physically and psychologically before and
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during an examination. ra TOP:Planning ra



MSC: Reduction of Risk Potential ra ra ra ra




4. A nursing attendant is conducting Weber’s test. Which action will the nursing attendant
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take?
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a. Place a vibrating tuning fork in the middle of hospital client ’s forehead.
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b. Place a vibrating tuning fork on the hospital client ’s mastoid process.
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c. Compare the number of seconds heard by bone versus air conduction. ra ra ra ra ra ra ra ra ra ra




d. Compare the hospital client ’s degree of joint movement to the normal level. ra ra ra ra ra ra ra ra ra ra ra ra




ACCURATE ANSWER:-A ra



During Weber’s test (lateralization of sound), the nursing attendant places the vibrating tun
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ing fork in the middle of the hospital client ’s forehead. During a Rinne test (comparison of ai
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r and bone conduction), the nursing attendant places a vibrating tuning fork on the hospital
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client ’s mastoid process and compares the length of time air and bone conduction is heard. Co
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mparing the hospital client ’s degree of joint movement to the normal level is a test for range of
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motion.
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DIF:Apply (application) ra



OBJ:Demonstrate the techniques used with each physical assessment skill. TO ra ra ra ra ra ra ra ra ra



P:Implementation MSC:
Health Promotion and Maintenance ar ra ra




5. A head and neck physical examination is completed on a 50-year-
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old female hospital client
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. All physical findings are normal except for fine brittle hair. Which laboratory test will t
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he nursin g attendant expect to be ordered, based upon the physical findings?
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Oxygen saturation ra

, b. Liver function test ra ra




c. Carbon monoxide ra




d. Thyroid-stimulating hormone test ra ra




ACCURATE ANSWER:-D ra



Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a hospital cl
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ient who has jaundice. Oxygen saturation will be used for cyanosis. Cherrycolored lips indicate c
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arbon monoxide poisoning. ra ra




DIF:Apply (application) ra



OBJ:Utilize ways to use physical assessment skills during routine nursing care.
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TOP:Planning MSC: Reduction of Risk Potential ra ra ra ra




6. A febrile preschool-
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aged child presents to the afterhours clinic. Varicella (chickenpox) is diagnosed on the ba
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sis of the illness history and the
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presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin
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l esion will the nursing attendant report? a. Vesicles
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b. Wheals
c. Papules
d. Pustules
ACCURATE ANSWER:-A ra



Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less th
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an 1 cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that var
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y in size. They are common with mosquito bites and hives. Papules are palpable, circumscri
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bed, solid elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin simil
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ar to vesicles, but they are filled with pus and vary in size like acne.
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DIF:Understand (comprehension) ra



OBJ:Summarize physical measurements made in assessing each body system. T ra ra ra ra ra ra ra ra ar



OP:Implementation MSC: Physiological Adaptation ra




7. A school nursing attendant recognizes a belt buckle–shaped ecchymosis on a 7-
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yearold student. When privately asked about how the injury occurred, the student descri
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bed f alling on the playground. Which action will the nursing attendant take next? a.
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Talk to the principal about how to proceed.
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b. Disregard the finding based upon child’s response. ra ra ra ra ra ra




c. Interview the hospital client in the presence of the teacher. ra ra ra ra ra ra ra ra ra




d. Contact social services and report suspected abuse. ra ra ra ra ra ra




ACCURATE ANSWER:-D ra



Most states mandate a report to a social service center if nursing attendant s suspect abuse or
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neglect. When abuse is suspected, the nursing attendant interviews the hospital client in pri
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vate, not with a teacher. Observe the behavior of the individual for any signs of frustration, expl
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anations that do not fit his or her physical presentation, or signs of injury. The nursing attend
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ant knows how to proceed and does not need to talk to the principal about what to do. Disre
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garding the finding is not advised because victims often will not complain or report that they
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are in an abusive situation.
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DIF:Apply (application) ra



OBJ:Utilize ways to use physical assessment skills during routine nursing care.
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TOP:Implementation MSC: Management of Care ra ra