Health Assessment and Physical Examination|
Questions & Essays with 100% Verified
Answers
On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the
second inpatient day. Which condition will the nurse assess for in this patient?
a. Anorexia
b. Weight loss
c. Fluid retention
d. Increased nutritional intake - ✔ ✔ ANS: C
This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or
more in a day indicates fluid retention problems, not nutritional intake. A weight loss is
considered significant if the patient has lost more than 5% of body weight in a month or 10%
in 6 months. A downward trend may indicate a reduction in nutritional reserves that may be
caused by decreased intake such as anorexia.
The patient is a 45-year-old African-American male who has come in for a routine annual
physical. Which type of preventive screening does the nurse discuss with the patient?
,a. Digital rectal examination of the prostate
b. Complete eye examination every year
c. CA 125 blood test once a year
d. Colonoscopy every 3 years - ✔ ✔ ANS: A
Recommended preventive screenings include a digital rectal examination of the prostate and
prostate-specific antigen test starting at age 50. CA 125 blood tests are indicated for women at
high risk for ovarian cancer. Patients over the age of 65 need to have complete eye
examinations yearly. Colonoscopy every 10 years is recommended in patients 50 years of age
and older.
An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old
American woman of Chinese descent. Which action will the nurse do first?
a. Place the patient in the lithotomy position.
b. Drape the patient to enhance patient comfort.
c. Assess the patient's feelings about the examination.
d. Ask the patient if she would like her mother to be present in the room. - ✔ ✔ ANS: C
Patients who are Chinese American often believe that examination of the external genitalia is
offensive. Before proceeding with the examination, the nurse first determines how the patient
feels about the procedure and explains the procedure to answer any questions and to help the
patient feel comfortable with the assessment. Once the patient is ready to have her external
genitalia examined, the nurse places the patient in the lithotomy position and drapes the
, patient appropriately. Typically, nurses ask adolescents if they want a parent present during the
examination. The patient in this question is 25 years old; asking if she would like her mother to
be present is inappropriate.
An older-adult patient is being seen for chronic entropion. Which condition will the nurse
assess for in this patient?
a. Ptosis
b. Infection
c. Borborygmi
d. Exophthalmos - ✔ ✔ ANS: B
The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and
cornea. Irritation can lead to infection. Exophthalmos is a bulging of the eyes and usually
indicates hyperthyroidism. An abnormal drooping of the lid over the pupil is called ptosis. In
the older adult, ptosis results from a loss of elasticity that accompanies aging. Hyperactive
sounds are loud, "growling" sounds called borborygmi, which indicate increased GI motility.
During a school physical examination, the nurse reviews the patient's current medical
history. The nurse discovers the patient has allergies. Which assessment finding is consistent
with allergies?
a. Clubbing
b. Yellow discharge
c. Pale nasal mucosa
Questions & Essays with 100% Verified
Answers
On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the
second inpatient day. Which condition will the nurse assess for in this patient?
a. Anorexia
b. Weight loss
c. Fluid retention
d. Increased nutritional intake - ✔ ✔ ANS: C
This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or
more in a day indicates fluid retention problems, not nutritional intake. A weight loss is
considered significant if the patient has lost more than 5% of body weight in a month or 10%
in 6 months. A downward trend may indicate a reduction in nutritional reserves that may be
caused by decreased intake such as anorexia.
The patient is a 45-year-old African-American male who has come in for a routine annual
physical. Which type of preventive screening does the nurse discuss with the patient?
,a. Digital rectal examination of the prostate
b. Complete eye examination every year
c. CA 125 blood test once a year
d. Colonoscopy every 3 years - ✔ ✔ ANS: A
Recommended preventive screenings include a digital rectal examination of the prostate and
prostate-specific antigen test starting at age 50. CA 125 blood tests are indicated for women at
high risk for ovarian cancer. Patients over the age of 65 need to have complete eye
examinations yearly. Colonoscopy every 10 years is recommended in patients 50 years of age
and older.
An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old
American woman of Chinese descent. Which action will the nurse do first?
a. Place the patient in the lithotomy position.
b. Drape the patient to enhance patient comfort.
c. Assess the patient's feelings about the examination.
d. Ask the patient if she would like her mother to be present in the room. - ✔ ✔ ANS: C
Patients who are Chinese American often believe that examination of the external genitalia is
offensive. Before proceeding with the examination, the nurse first determines how the patient
feels about the procedure and explains the procedure to answer any questions and to help the
patient feel comfortable with the assessment. Once the patient is ready to have her external
genitalia examined, the nurse places the patient in the lithotomy position and drapes the
, patient appropriately. Typically, nurses ask adolescents if they want a parent present during the
examination. The patient in this question is 25 years old; asking if she would like her mother to
be present is inappropriate.
An older-adult patient is being seen for chronic entropion. Which condition will the nurse
assess for in this patient?
a. Ptosis
b. Infection
c. Borborygmi
d. Exophthalmos - ✔ ✔ ANS: B
The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and
cornea. Irritation can lead to infection. Exophthalmos is a bulging of the eyes and usually
indicates hyperthyroidism. An abnormal drooping of the lid over the pupil is called ptosis. In
the older adult, ptosis results from a loss of elasticity that accompanies aging. Hyperactive
sounds are loud, "growling" sounds called borborygmi, which indicate increased GI motility.
During a school physical examination, the nurse reviews the patient's current medical
history. The nurse discovers the patient has allergies. Which assessment finding is consistent
with allergies?
a. Clubbing
b. Yellow discharge
c. Pale nasal mucosa
