Health Assessment and Physical Examination (P&P)
Chapter 31: with all Correct & 100% Verified Answers |
Latest Update |Already Graded A+
A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient,
the new graduate nurse begins to explain to the patient the purpose of completing a physical
assessment. Which statement made by the new graduate nurse requires the preceptor to intervene?
a. "I will use the information from my assessment to figure out if your antihypertensive medication is
working effectively."
b. "Nursing assessment data are used only to provide information about the effectiveness of your
medical care."
c. "Nurses use data from their patient's physical assessment to determine a patient's educational
needs."
d. "Information gained from physical assessment helps nurses better understand their patients'
emotional needs." ✔Correct Answer-b. "Nursing assessment data are used only to provide
information about the effectiveness of your medical care."
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not
just the patient's medical care. Assessment data help to evaluate the effectiveness of medications
and to determine a patient's health care needs, including the need for patient
education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.
2. Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters
the patient's room and identifies self, washes hands with soap, and states the purpose of the visit.
The nurse performs proper identification of the patient before auscultating the patient's lungs.
Which critical health assessment step should the nurse have performed?
a. Running warm water over stethoscope
b. Draping stethoscope around the neck
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol ✔Correct Answer-d. Cleaning stethoscope with alcohol
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean
is used. The stethoscope should be cleaned before use on each patient with isopropyl
alcohol. Running water over the stethoscope does not kill bacteria. Betadine is an inappropriate
cleaning solution and may damage the equipment. Draping the stethoscope around the neck is not
advised.
A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with
bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims'
c. Supine
d. Lateral recumbent ✔Correct Answer-c. Supine
, Supine is the most normally relaxed position. If the patient becomes short of breath easily, raise the
head of the bed. Supine position would be easiest for a weak, older-adult person during the
examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with
respiratory difficulties. Sims' position is used for assessment of the rectum and the vagina.
A nurse is conducting Weber's test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient's forehead.
b. Place a vibrating tuning fork on the patient's mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient's degree of joint movement to the normal level. ✔Correct Answer-a. Place
a vibrating tuning fork in the middle of patient's forehead
During Weber's test (lateralization of sound), the nurse places the vibrating tuning fork in the middle
of the patient's forehead. During a Rinne test (comparison of air and bone conduction), the nurse
places a vibrating tuning fork on the patient's mastoid process and compares the length of time air
and bone conduction is heard. Comparing the patient's degree of joint movement to
the normal level is a test for range of motion.
A head and neck physical examination is completed on a 50-year-old female patient. All physical
findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be
ordered, based upon the physical findings?
a. Oxygen saturation
b. Liver function test
c. Carbon monoxide
d. Thyroid-stimulating hormone test ✔Correct Answer-d. Thyroid-stimulating hormone test
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who
has jaundice. Oxygen saturation will be used for cyanosis. Cherry-colored lips indicate carbon
monoxide poisoning.
A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is diagnosed
on the basis of the illness history and the presence of small, circumscribed skin lesions filled with
serous fluid. Which type of skin lesion will the nurse report?
a. Vesicles
b. Wheals
c. Papules
d. Pustules ✔Correct Answer-a. Vesicles
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1cm.
Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They
are common with mosquito bites and hives. Papules are palpable, circumscribed, solid elevations in
the skin that are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are
filled with pus and vary in size like acne.
A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When
privately asked about how the injury occurred, the student described falling on the playground.
Which action will the nurse take next?
Chapter 31: with all Correct & 100% Verified Answers |
Latest Update |Already Graded A+
A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient,
the new graduate nurse begins to explain to the patient the purpose of completing a physical
assessment. Which statement made by the new graduate nurse requires the preceptor to intervene?
a. "I will use the information from my assessment to figure out if your antihypertensive medication is
working effectively."
b. "Nursing assessment data are used only to provide information about the effectiveness of your
medical care."
c. "Nurses use data from their patient's physical assessment to determine a patient's educational
needs."
d. "Information gained from physical assessment helps nurses better understand their patients'
emotional needs." ✔Correct Answer-b. "Nursing assessment data are used only to provide
information about the effectiveness of your medical care."
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not
just the patient's medical care. Assessment data help to evaluate the effectiveness of medications
and to determine a patient's health care needs, including the need for patient
education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.
2. Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters
the patient's room and identifies self, washes hands with soap, and states the purpose of the visit.
The nurse performs proper identification of the patient before auscultating the patient's lungs.
Which critical health assessment step should the nurse have performed?
a. Running warm water over stethoscope
b. Draping stethoscope around the neck
c. Rubbing stethoscope with betadine
d. Cleaning stethoscope with alcohol ✔Correct Answer-d. Cleaning stethoscope with alcohol
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean
is used. The stethoscope should be cleaned before use on each patient with isopropyl
alcohol. Running water over the stethoscope does not kill bacteria. Betadine is an inappropriate
cleaning solution and may damage the equipment. Draping the stethoscope around the neck is not
advised.
A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with
bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims'
c. Supine
d. Lateral recumbent ✔Correct Answer-c. Supine
, Supine is the most normally relaxed position. If the patient becomes short of breath easily, raise the
head of the bed. Supine position would be easiest for a weak, older-adult person during the
examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with
respiratory difficulties. Sims' position is used for assessment of the rectum and the vagina.
A nurse is conducting Weber's test. Which action will the nurse take?
a. Place a vibrating tuning fork in the middle of patient's forehead.
b. Place a vibrating tuning fork on the patient's mastoid process.
c. Compare the number of seconds heard by bone versus air conduction.
d. Compare the patient's degree of joint movement to the normal level. ✔Correct Answer-a. Place
a vibrating tuning fork in the middle of patient's forehead
During Weber's test (lateralization of sound), the nurse places the vibrating tuning fork in the middle
of the patient's forehead. During a Rinne test (comparison of air and bone conduction), the nurse
places a vibrating tuning fork on the patient's mastoid process and compares the length of time air
and bone conduction is heard. Comparing the patient's degree of joint movement to
the normal level is a test for range of motion.
A head and neck physical examination is completed on a 50-year-old female patient. All physical
findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be
ordered, based upon the physical findings?
a. Oxygen saturation
b. Liver function test
c. Carbon monoxide
d. Thyroid-stimulating hormone test ✔Correct Answer-d. Thyroid-stimulating hormone test
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who
has jaundice. Oxygen saturation will be used for cyanosis. Cherry-colored lips indicate carbon
monoxide poisoning.
A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is diagnosed
on the basis of the illness history and the presence of small, circumscribed skin lesions filled with
serous fluid. Which type of skin lesion will the nurse report?
a. Vesicles
b. Wheals
c. Papules
d. Pustules ✔Correct Answer-a. Vesicles
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1cm.
Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They
are common with mosquito bites and hives. Papules are palpable, circumscribed, solid elevations in
the skin that are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are
filled with pus and vary in size like acne.
A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When
privately asked about how the injury occurred, the student described falling on the playground.
Which action will the nurse take next?
