Examination-Chapter 3 100%
ANSWERED
1. A patient who is actively bleeding is admitted to the emergency department. Which
approach should the nurse use to obtain an accurate health history?
a. Briefly interview the patient while obtaining vital signs.
b. Obtain subjective data about the patient from family members.
c. Omit subjective data collection and obtain the physical examination.
d. Use the health care provider's medical history to obtain subjective data. –
Answer: a. Briefly interview the patient while obtaining vital signs.
Rationale: In an emergency situation, the nurse may need to ask only the most pertinent
questions for a specific problem and obtain more information later. A complete health
history will include subjective information that is not available in the health care
provider's medical history. Family members may be able to provide some data, but only
the patient will be able to give subjective information about the bleeding. Because the
subjective data about the cause of the patient's bleeding will be essential, obtaining the
physical examination alone will not provide sufficient information.
2. Immediate surgery is planned for a patient with acute abdominal pain. Which
question by the nurse will elicit direct information about the patient's coping-stress
tolerance pattern?
a. "Can you rate your pain on a 0 to 10 scale?"
b. "What do you think caused this abdominal pain?"
c. "Are there other problems or concerns right now?"
d. "How do you feel about yourself and being hospitalized?" –
Answer: c. "Are there other problems or concerns right now?"
Rationale: The coping-stress tolerance pattern includes information about other major
stressors confronting the patient. The health perception-health management pattern
includes information about the patient's ideas about risk factors. Feelings about self and
the hospitalization are assessed in the self-perception-self-concept pattern. Intensity of
pain is part of the cognitive-perceptual pattern.
3. During the health history interview, a patient tells the nurse about periodic fainting
spells. Which question should the nurse ask to elicit any associated clinical
manifestations?
a. "How frequently do you have the fainting spells?"
b. "Do the spells occur at any particular time of day?"
c. "Where are you when you have the fainting spells?"
, d. "Do you have other symptoms along with the spells?" –
Answer: d. "Do you have other symptoms along with the spells?"
Rationale: Asking about other associated symptoms will provide the nurse more
information about all the clinical manifestations related to the fainting spells. Information
about the setting is obtained by asking where the patient was and what the patient was
doing when the symptom occurred. The other questions from the nurse are appropriate
for obtaining information about chronology and frequency.
4. The nurse records the following general survey: "The patient is a 50-year-old Asian
female accompanied by her husband and two daughters. Alert and oriented. Does not
make eye contact with the nurse and responds slowly, but appropriately, to questions.
No apparent disabilities or distinguishing features." What additional information should
the nurse add to this general survey?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about the condition –
Answer: a. Nutritional status.
Rationale: The general survey also describes the patient's general nutritional status.
The other information will be obtained when doing the complete nursing history and
examination but is not obtained through the initial scanning of a patient.
5. A nurse performs a health history and physical examination with a patient who has a
right leg fracture. Which assessment would be a pertinent negative finding?
a. Patient has several bruised and swollen areas on the right leg.
b. Patient states that there have been no other recent health problems.
c. Patient refuses to bend the right knee because of the associated pain.
d. Patient denies having pain when the area over the fracture is palpated. –
Answer: d. Patient denies having pain when the area over the fracture is palpated.
Rationale: The nurse expects that a patient with a leg fracture will have pain over the
fractured area. The bruising and swelling and pain with bending are positive findings.
Having no other recent health problems is neither a positive nor a negative finding with
regard to a leg fracture.
6. The nurse asks an older adult patient with rectal bleeding, "Have you ever had a
colonoscopy?" The nurse is performing what type of assessment?
a. Focused assessment
b. Emergency assessment
c. Detailed health assessment
d. Comprehensive assessment