ch. 22 health assessment test bank
During a health interview, an elderly patient has difficulty remembering information about the
health history. In order to get the information more reliably, the nurse should: - ANSc. gather
information from a family member accompanying the patient
It is the responsibility of the nurse to perform a quick focused assessment of the patient upon: -
ANSc. the beginning of each shift
When performing deep palpation, the nurse should use: - ANSc. either one or two hands to
depress the tissue about 1.5 to 2 inches
The nurse weighing an infant in an outpatient clinic should: - ANSc. keep one hand hovering
over the infant during the weighing procedure
The nurse taking a blood pressure should: - ANSc. request that the patient put feet flat on the
floor
When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be
placed on the: - ANSa. 5th intercostal space, left midclavicular line.
A nurse caring for a patient on bed rest with a history of respiratory health problems should: -
ANSc. auscultate lung sounds at the beginning of a shift.
The nurse is aware that the best way to assess dependent pitting edema in a patient with
congestive heart failure is to: - ANSd. press fingers into the tissue over the tibia, just above the
ankle
a nurse records absence of bowel sounds after assessing the abdomen in: - ANSc. all
quadrants for 3 min each
The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can
open his eyes spontaneously, obeys all commands, and its oriented. The nurse documents a
score of: - ANSd. 15
When examining a pt.'s pupils with a light, the nurse notes that both pupils constrict, regardless
of which eye isimulated by the light. The nurse should document - ANSa. consensual response
To correctly determine the strength of a pt.'s lower extremities during a neurologic examination,
the nurse asks the pt to: - ANSc. pull both feet u at the same time to strech the achilles tendons
During a health interview, an elderly patient has difficulty remembering information about the
health history. In order to get the information more reliably, the nurse should: - ANSc. gather
information from a family member accompanying the patient
It is the responsibility of the nurse to perform a quick focused assessment of the patient upon: -
ANSc. the beginning of each shift
When performing deep palpation, the nurse should use: - ANSc. either one or two hands to
depress the tissue about 1.5 to 2 inches
The nurse weighing an infant in an outpatient clinic should: - ANSc. keep one hand hovering
over the infant during the weighing procedure
The nurse taking a blood pressure should: - ANSc. request that the patient put feet flat on the
floor
When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be
placed on the: - ANSa. 5th intercostal space, left midclavicular line.
A nurse caring for a patient on bed rest with a history of respiratory health problems should: -
ANSc. auscultate lung sounds at the beginning of a shift.
The nurse is aware that the best way to assess dependent pitting edema in a patient with
congestive heart failure is to: - ANSd. press fingers into the tissue over the tibia, just above the
ankle
a nurse records absence of bowel sounds after assessing the abdomen in: - ANSc. all
quadrants for 3 min each
The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can
open his eyes spontaneously, obeys all commands, and its oriented. The nurse documents a
score of: - ANSd. 15
When examining a pt.'s pupils with a light, the nurse notes that both pupils constrict, regardless
of which eye isimulated by the light. The nurse should document - ANSa. consensual response
To correctly determine the strength of a pt.'s lower extremities during a neurologic examination,
the nurse asks the pt to: - ANSc. pull both feet u at the same time to strech the achilles tendons
