Fundamentals of Nursing Chapter 30:
Health Assessment and Physical
Examination with Solved Solutions.
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 of the following statements 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 care."
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 needs." - Answer b. "Nursing assessment data are used only to provide
information about the effectiveness of your medical care."
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care,
not just the patient's medical care. Assessment data help to evaluate the effectiveness of
medications and to determine a patient's health care needs, including the need for patient
education. Nurses also use assessment data to identify patients' psychosocial and cultural
needs.
Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters
the patient's room and identifies himself, washes his hands with soap, and states the purpose of
his visit. He performs proper identification of the patient before he auscultates her lungs. Which
critical health assessment step was not performed?
a. Running warm water over stethoscope for patient comfort
b. Cleaning stethoscope with Betadine
c. Using alcohol-based hand disinfectant
d. Cleaning stethoscope with alcohol - Answer d. Cleaning stethoscope with alcohol
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not
clean is used. The stethoscope should be cleaned before use on each patient. Running water
over the stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and
may damage the equipment. Hand sanitizer is not an approved cleaning product.
,Which is the best examination position for a complete geriatric physical examination on a weak
patient with bilateral basilar pneumonia?
a. Prone position
b. Sims' position
c. Supine position
d. Lateral recumbent - Answer c. Supine position
This is the most normally relaxed position. It will not compromise the patient's breathing
because it is likely compromised with pneumonia. If the patient becomes short of breath easily,
raise the head of the bed. This position would be easiest for an elderly weak person to get into
position for an examination. Lateral recumbent and prone positions cause respiratory difficulty
for any patient with respiratory difficulties. Sims' position is used for assessment of the rectum
and the vagina.
During an annual gynecological examination, a college student discusses her upcoming college
break at a tropical location. After the student receives an oral contraceptive prescription, the
nurse identifies the importance of skin cancer prevention education by discussing which
evidence-based prevention health topic?
a. Applying water-based sunscreen only before swimming
b. Using tanning bed daily for 7 days before college break trip
c. Applying broad-spectrum sunscreen of SPF 5
d. Taking extra precautions in the sun secondary to the prescription - Answer d. Taking extra
precautions in the sun secondary to the prescription
Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient
should be educated about the need for sun protection such as wide-brimmed hats, use of
broad-spectrum sunscreen of SPF 15 or greater, not tanning during midday, and not using
tanning beds. Broad-spectrum sunscreens should be applied 15 minutes before going into the
sun and after swimming or perspiring. Tanning parlors, sunlamps, etc., should be avoided.
Sunscreens with SPF of 15 or greater should be used.
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. Based on the physical findings, which of the
following laboratory tests would the nurse expect to be ordered?
a. Liver function test
b. Lead level
c. Thyroid-stimulating hormone test
, d. Complete blood count - Answer c. Thyroid-stimulating hormone test
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient
who has jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.
A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the
basis of the illness history and the presence of small, circumscribed skin lesions filled with
serous fluid. The nurse documents the varicellar lesions as which type of skin lesion?
a. Vesicle
b. Wheal
c. Papule
d. Pustule - Answer a. Vesicle
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1
cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in
size. They are common with bug bits and hives. Papules are palpable, circumscribed, solid
elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to
vesicles, but they are filled with pus.
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.
Upon suspecting abuse, the school nurse's best next action is which of the following?
a. Interviewing the patient in the presence of his/her teacher
b. Ignoring the findings because child abuse is a declining problem
c. Realizing that abuse victims usually report abusive situations
d. Contacting Social Services and reporting suspected abuse - Answer d. Contacting Social
Services and reporting suspected abuse
Most states mandate a report to a social service center if nurses suspect abuse or neglect.
When abuse is suspected, the nurse interviews the patient in private. Abuse of children,
women, and older adults is a growing health problem. It is difficult to detect abuse because
victims often will not complain or report that they are in an abusive situation.
A nurse identifies Pediculosis humananus capitis. Considering the possible complications of
treatment, the nurse knows to not use which of the following treatment products?
a. Fine-toothed comb
Health Assessment and Physical
Examination with Solved Solutions.
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 of the following statements 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 care."
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 needs." - Answer b. "Nursing assessment data are used only to provide
information about the effectiveness of your medical care."
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care,
not just the patient's medical care. Assessment data help to evaluate the effectiveness of
medications and to determine a patient's health care needs, including the need for patient
education. Nurses also use assessment data to identify patients' psychosocial and cultural
needs.
Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters
the patient's room and identifies himself, washes his hands with soap, and states the purpose of
his visit. He performs proper identification of the patient before he auscultates her lungs. Which
critical health assessment step was not performed?
a. Running warm water over stethoscope for patient comfort
b. Cleaning stethoscope with Betadine
c. Using alcohol-based hand disinfectant
d. Cleaning stethoscope with alcohol - Answer d. Cleaning stethoscope with alcohol
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not
clean is used. The stethoscope should be cleaned before use on each patient. Running water
over the stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and
may damage the equipment. Hand sanitizer is not an approved cleaning product.
,Which is the best examination position for a complete geriatric physical examination on a weak
patient with bilateral basilar pneumonia?
a. Prone position
b. Sims' position
c. Supine position
d. Lateral recumbent - Answer c. Supine position
This is the most normally relaxed position. It will not compromise the patient's breathing
because it is likely compromised with pneumonia. If the patient becomes short of breath easily,
raise the head of the bed. This position would be easiest for an elderly weak person to get into
position for an examination. Lateral recumbent and prone positions cause respiratory difficulty
for any patient with respiratory difficulties. Sims' position is used for assessment of the rectum
and the vagina.
During an annual gynecological examination, a college student discusses her upcoming college
break at a tropical location. After the student receives an oral contraceptive prescription, the
nurse identifies the importance of skin cancer prevention education by discussing which
evidence-based prevention health topic?
a. Applying water-based sunscreen only before swimming
b. Using tanning bed daily for 7 days before college break trip
c. Applying broad-spectrum sunscreen of SPF 5
d. Taking extra precautions in the sun secondary to the prescription - Answer d. Taking extra
precautions in the sun secondary to the prescription
Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient
should be educated about the need for sun protection such as wide-brimmed hats, use of
broad-spectrum sunscreen of SPF 15 or greater, not tanning during midday, and not using
tanning beds. Broad-spectrum sunscreens should be applied 15 minutes before going into the
sun and after swimming or perspiring. Tanning parlors, sunlamps, etc., should be avoided.
Sunscreens with SPF of 15 or greater should be used.
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. Based on the physical findings, which of the
following laboratory tests would the nurse expect to be ordered?
a. Liver function test
b. Lead level
c. Thyroid-stimulating hormone test
, d. Complete blood count - Answer c. Thyroid-stimulating hormone test
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient
who has jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.
A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the
basis of the illness history and the presence of small, circumscribed skin lesions filled with
serous fluid. The nurse documents the varicellar lesions as which type of skin lesion?
a. Vesicle
b. Wheal
c. Papule
d. Pustule - Answer a. Vesicle
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1
cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in
size. They are common with bug bits and hives. Papules are palpable, circumscribed, solid
elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to
vesicles, but they are filled with pus.
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.
Upon suspecting abuse, the school nurse's best next action is which of the following?
a. Interviewing the patient in the presence of his/her teacher
b. Ignoring the findings because child abuse is a declining problem
c. Realizing that abuse victims usually report abusive situations
d. Contacting Social Services and reporting suspected abuse - Answer d. Contacting Social
Services and reporting suspected abuse
Most states mandate a report to a social service center if nurses suspect abuse or neglect.
When abuse is suspected, the nurse interviews the patient in private. Abuse of children,
women, and older adults is a growing health problem. It is difficult to detect abuse because
victims often will not complain or report that they are in an abusive situation.
A nurse identifies Pediculosis humananus capitis. Considering the possible complications of
treatment, the nurse knows to not use which of the following treatment products?
a. Fine-toothed comb
