Chapter 21. Physical Assessment A Graded

A nurse wakes the patient for a focused assessment. The patient, trying to rest, tells the nurse, “I wish you would quit waking me up. Do you really need to keep bothering me?” The nurse appropriately responds: 1. “Most patients would love to get the attention that you are getting.” 2. “I understand your frustration, but this has been ordered by your physician.” 3. “It is necessary that I do a head-to-toe assessment from which I can determine whether there are any changes in your condition.” 4. “It is important to assess your blood pressure and pulse since we just started your new blood pressure medicine.” ____ 2. After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the patient’s plan of care. This decision is a result of the nurse’s 1. Ensuring that each patient receives a comprehensive health assessment. 2. Evaluating the effectiveness of nursing interventions. 3. Reviewing the organizational plan for the shift. 4. Learning that the patient may be discharged from the hospital during this shift. ____ 3. When performing a physical assessment of a patient, a nurse uses the five techniques of obtaining objective data. The technique that provides data by using the hands is 1. Palpation. 2. Auscultation. 3. Observation. 4. Olfaction