NSG 6020 Week 5 Midterm Study Guide NSG 6020 Health Assessment

1. A patient tells the nurse that she has had abdominal pain for the past week. What would be the best response by the nurse? 1. “Can you point to where it hurts?” 2. “We’ll talk more about that later in the interview.” 3. “What have you had to eat in the last 24 hours?” 4. “Have you ever had any surgeries on your abdomen?” ANS: 1 A final summary of any symptom the person has should include, along with seven other critical characteristics, “Location: specific.” Ask the person to point to the location. 2. A patient’s laboratory data reveal an elevated thyroxine level. The nurse would proceed with anexamination of the: thyroid 3. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the examiner do first? Auscultate the lungs and heart while the infant is still sleeping. 4. When preparing to examine a 6-year-old child, which action is most appropriate? Start with the thorax, abdomen, and genitalia before examining the head. Avoid talking about the equipment being used because it may increase the child’s anxiety. Keep in mind that a child this age will have a sense of modesty. Have the child undress from the waist up. 5. 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: she may have macular degeneration 6. In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history? 1.Family history, hypertension, stress, age 2.Personality type, high cholesterol, diabetes, smoking 3.Smoking, hypertension, obesity, diabetes, high cholesterol 4.Alcohol consumption, obesity, diabetes, stress, high cholesterol ANS: 3 For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dl or known diabetes mellitus, obesity, cigarette smoking, low activity level. 7. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: B) a pneumothorax. 8. During a hearing assessment the nurse practitioner finds that sound lateralizes to the patient’s left ear with the Weber test. What can the nurse practitioner conclude from this? The patient has a conductive hearing loss in the right ear. Lateralization is a normal finding with the Weber test. The patient could have either a sensorineural or a conductive loss. A mistake has occurred; the test must be repeated. 9. The most important reason to share information and offer brief teaching while performing the physical examination is to help: examiner feel more comfortable and gain control of the situation. rapport and increase the patient’s confidence in the examiner. patient understand his or her disease process and treatment modalities. patient identify questions about his or her disease and potential areas of patient education. rapport and increase the patient’s confidence in the examiner. 10. In assessing the sclera of a black patient, which of the following would be an expected finding? The presence of small brown macules on the sclera 11. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? Using gentle pressure, palpate with both hands to compare the two sides. 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of the following questions would be appropriate to use to assess health promotion activities for this patient? 1. “Do you perform testicular self-exams?” 2. “Have you ever noticed any pain in your testicles?” 3. “Have you had any problems with passing your urine?” 4. “Do you have any history of sexually transmitted disease?” ANS: 1