Health Assessment & Physical Examination

Chapter 30 - Health Assessment & Physical Examination 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 ca 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 ne - ANS: B 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 - ANS: D 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 - ANS: C 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. - ANS: A 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 - ANS: D 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 - ANS: A 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? a. Talk to the principal about how to proceed. b. Disregard the finding based upon child's response. c. Interview the patient in the presence of the teacher. d. Contact social services and report suspected abuse. - ANS: D A nurse identifies lice during a child's scalp assessment. The nurse teaches the parents about hair care. Which information from the parents indicates the nurse needs to follow up? a. We will use lindane-based shampoos. b. We will use the sink to wash hair. c. We will use a fine-toothed comb. d. We will use a vinegar hair rinse. - ANS: A A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Which response by the nurse is the best regarding the eye examination results? a. Your child needs to see an ophthalmologist. b. Your child is suffering from strabismus. c. Your child may have presbyopia. d. Your child has cataracts. - ANS: A During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born and developed an infection that required "every antibiotic under the sun" to reach a cure. Which exam is a priority for the nurse to conduct on the child? a. Cardiac b. Respiratory c. Ophthalmic