NUR 2092 / NUR2092: Health Assessment Exam Quiz Bank | Questions and Answers with Rationales | 2023 | Rasmussen College Graded A+

NUR 2092 / NUR2092: Health Assessment Exam Quiz Bank | Questions and Answers with Rationales | 2023 | Rasmussen College Graded A+. The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate? a. Asking questions enhances the child’s autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like to have choices d. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available RAT: Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?” 16. With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent RAT: When assessing preschool children, using games or allowing them to play with the equipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups. 17. The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Explain the procedures in detail to alleviate the child’s anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen. RAT: With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler. 18. When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because a teen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. RAT: During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development. 19. When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes as possible. RAT: When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished. 20. The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients. RAT: The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed. 21.Which of these statements is true regarding the use of Standard Precautions in the health care setting? a. Standard Precautions apply to all body fluids, including sweat. b. Use alcohol-based hand rub if hands are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present. RAT: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat— regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. 22. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b. A thorough history and physical assessment information should be obtained from the patient’s family member. c. A complete history and physical assessment should be immediately performed to obtain baseline information. d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved. RAT: Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress is resolved. 23. When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen RAT: The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last. 24. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse’s palm of the hand RAT: The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds. 25. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. RAT: The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.