Chapter 3. Health History and Physical Examination

Chapter 03: Health History and Physical Examination Lewis: Medical-Surgical Nursing in Canada, MULTIPLE CHOICE 1. An older-adult client who is having difficulty breathing is admitted to the hospital. Which of the following approaches is the best for the nurse to use to obtain a complete health history? a. Obtain subjective data about the client from family members. b. Omit subjective data collection and obtain the physical examination. c. Use the health care provider’s medical history to obtain subjective data. d. Schedule several short sessions with the client to gather subjective data. ANS: D In the case of an older-adult client with a low energy level, several short sessions may have to be scheduled. Allowing time for the client to volunteer information about particular areas of concern enables the nurse to work with the client to identify existing and potential health problems. 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 subjective data, but only the client will be able to give subjective information about the shortness of breath. Since the subjective data about the client’s respiratory status will be essential, obtaining the physical examination alone will not provide sufficient information. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance N U R S I N G T B.C O M 2. Immediate surgery is planned for a client with acute abdominal pain. Which of the following questions will elicit the most complete information about the client’s coping-stress tolerance pattern? a. “Can you tell me how intense your pain is now?” b. “What do you think caused this abdominal pain?” c. “How do you feel about yourself and your hospitalization?” d. “Are there other major problems that are a concern right now?” ANS: D The coping-stress tolerance pattern includes information about other major stressors confronting the client. The health perception–health management pattern includes information about the client’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. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. During the health history interview, a client tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur? a. “How frequently do you have the fainting spells?” b. “Where are you when you have the fainting spells?” c. “Do the spells tend to occur at any special time of day?” d. “Do you have any other symptoms along with the spells?” ANS: B Information about the setting is obtained by asking where the client was and what the client was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology, frequency, and associated clinical manifestations. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse records the following general survey of a client: “The client is a 68-year-old male Asian accompanied by his wife 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.” Which of the following information should be added to this general survey documentation? a. Nutritional status b. Intake and output c. Reasons for contact with the health care system d. Comments of family members about his condition ANS: A The general survey also describes the client’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 client. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance N U R S I N G T B.C O M 5. A nurse is performing a health history and physical examination for a client with right-sided rib fractures. Which of the following data is a pertinent negative finding? a. Client states that there have been no other health problems recently. b. Client denies having pain when the area over the fractures is palpated. c. Client has several bruised and swollen areas on the right anterior chest. d. Client refuses to take a deep breath because of the associated chest pain. ANS: B The nurse expects that a client with rib fractures will have pain over the fractured area. The first statement is neither a positive nor a negative finding with regard to the rib fractures. The bruising and swelling and pain with breathing are positive findings. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardly move it.” This client statement indicates the nurse should perform which of the following assessments? a. Focused b. Screening c. Emergency d. Comprehensive ANS: A The focused assessment is needed when a client has clinical manifestations that indicate a problem. An emergency assessment is done when the nurse needs to obtain information about life-threatening problems quickly while simultaneously taking action to maintain vital function. The screening assessment is not recognized as one of the three main types of assessment. A comprehensive assessment is a detailed health history and physical examination. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is preparing to perform a focused abdominal assessment for a client who has high-pitched bowel sounds. Which equipment will be needed? a. Flashlight b. Stethoscope c. Tongue blades d. Percussion hammer ANS: B A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a comprehensive assessment, but will not be needed for a focused abdominal assessment. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. When the nurse is planning for the physical examination of an alert older-adult client, which of the following adaptations to the examination technique should be considered? N U R S I N G T B.C O a. Speaking slowly when directing the client. b. Avoiding the use of touch as much as possible. c. Using slightly more pressure for palpation of the liver. d. Organizing the sequence to minimize position changes. ANS: D M Older clients may have age-related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older clients. Less pressure should be used over the liver. Since the client is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. While the nurse is taking the health history, a client states, “My father and grandfather both had heart attacks and were unable to be very active afterwards.” This statement reflects which of the following functional health patterns? a. Activity-exercise b. Cognitive-perceptual c. Coping-stress tolerance d. Health perception–health management ANS: D The information in the client statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception–health maintenance pattern. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. A client is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time? a. Focused b. Subjective c. Emergency d. Comprehensive ANS: C Since the client is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the client is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable client. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. The nurse records the following general survey of a client: “The client is a 68-year-old Indigenous male accompanied by his wife 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.” Which of the following areas does the nurse need to assess to complete the general survey? N U R S I N G T B.C O a. Body movements b. Intake and output c. Reasons for contact with the health care system d. Comments of family members about his condition ANS: A M To complete a general survey, the nurse needs to assess the client’s body movements. Intake and output, reasons for contact with the health care system, and comments of family members about the client’s condition are not part of the general survey. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 12. When assessing the circulation to the lower leg of a client who has had knee surgery, which action should the nurse take first? a. Feel for the temperature of the foot. b. Visually inspect the colour of the foot. c. Check the client’s pedal pulses using the fingertips. d. Compress the nail beds to determine capillary refill time. ANS: B Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. When assessing a client’s abdomen during the admission assessment, which of these actions should the nurse take first? a. Feel for any masses. b. Palpate the abdomen. c. Percuss the liver borders. d. Listen to the bowel sounds. ANS: D When assessing the abdomen, auscultation is done before palpation or percussion because palpation and percussion can cause changes in bowel sounds and alter the findings. All of the techniques are appropriate, but auscultation should be done first. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. When admitting a client who has just arrived on the medical unit with severe abdominal pain, what should the nurse do first? a. Complete only basic demographic data before addressing the client’s abdominal pain. b. Medicate the client for the abdominal pain before attending to the health history and examination. c. Inform the client that the abdominal pain will be treated as soon as the health history is completed. d. Take the initial vital signs and then deal with the abdominal pain before completing the health history. ANS: D N U R S I N G T B.C O M The client priority in this situation will be to decrease the pain level because the client will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacological or nonpharmacological therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is completing a neurological assessment on an adult client. Which of the following assessments should the nurse include when assessing the client’s coordination? (Select all that apply.) a. Toe walk b. Finger to nose c. Drift d. Romberg e. Heel to opposite shin ANS: B, D, E A neurological assessment is completed to observe motor status by assessing gait, toe and heel walk, and drift whereas when assessing coordination, the nurse observes finger to nose, Romberg sign, and heel to opposite shin. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance