Chapter 21 Physical Assessment

Chapter 21  Physical Assessment

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. 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 responds
A.
“Most patients would love to get the attention that you are getting.”
B.
“I understand your frustration, but this has been ordered by your physician.”
C.
“It is necessary that I do a head-to-toe assessment from which I can determine if there are any changes in your condition.”
D.
“It is important to assess your blood pressure and pulse since we just started your new blood pressure medicine.”

____ 2. The nurse, after completing the initial head-to-toe assessment, determines that no changes are needed in the patient’s plan of care. This decision is a result of
A.
Ensuring that each one receives a comprehensive health assessment.
B.
Evaluating the effectiveness of nursing interventions.
C.
Reviewing the nurse’s organizational plan for the shift.
D.
Learning that the patient may be discharged from the hospital during this shift.

____ 3. A nurse uses the five techniques when performing a physical assessment on a patient. The technique that provides data by using the hands is
A.
Palpation.
B.
Auscultation.
C.
Observation.
D.
Olfaction.

____ 4. The patient’s blood pressure at 8 a.m. was 124/80 mm Hg, and at 12 p.m. it is 152/94 mm Hg. The charge nurse instructs the newly hired nurse that
A.
The blood pressure should be rechecked in 15 minutes.
B.
Any abnormal findings should be rechecked within 8 hours.
C.
Since the blood pressure has elevated, it should be rechecked in 1 to 2 hours.
D.
There is no reason to recheck the blood pressure because this is typical.

____ 5. At the staff education meeting, the nurse discusses that it is important to use the four senses to determine signs of illness or injury that a patient may be exhibiting. Signs are
A.
Subjective.
B.
Measureable.
C.
Reported by the patient.
D.
Hidden.

Physical Assessment
Answer Section

MULTIPLE CHOICE

1. ANS: D

Feedback
A
To decrease the patient’s frustration, it is best to explain the reason that the patient is being awakened for a focused assessment.
B
Although it may or may not have been ordered by the physician, it is better for the nurse to explain why he or she is doing the assessment.
C
A head-to-toe assessment is the first assessment of the shift and gives the nurse a quick overall picture of the patient.
D
A focused assessment involves the assessment of a system, which in this case is the cardiovascular system, to evaluate the patient’s response to new medication. Chapter Objective: Differentiate between a comprehensive health assessment, a focused assessment, and an initial head-to-toe shift assessment.

PTS: 1 REF: Chapter: 21 | Page: 422 OBJ: Chapter Objective: 21-3
KEY: Content Area: Psychosocial Integrity | Integrated Process: Communication and Documentation | Client Need: Psychosocial Integrity/Therapeutic Communication | Cognitive Level: Analysis

2. ANS: B

Feedback
A
A comprehensive health assessment on each patient is done upon admission.
B
Evaluating the effectiveness of nursing interventions is one reason for determining whether or not changes are necessary in a patient’s plan of care. Chapter Objective: Describe three purposes of physical assessment.
C
It may be necessary to change plans many times during the shift, but this is as a result of changes in patients, not the amount of time that the nurse has for the care to be provided.
D
Learning that the patient may be discharged will require changes in the plan of care, possibly geared more toward patient education.

PTS: 1 REF: Chapter: 21 | Page: 422 OBJ: Chapter Objective: 21-2
KEY: Content Area: Reduction of Risk Potential | Integrated Process: Nursing Process/Evaluation | Client Need: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems | Cognitive Level: Analysis

3. ANS: A

Feedback
A
Palpation is the application of hands to detect abnormalities. Chapter Objective: Summarize the six techniques used for physical assessment.
B
Auscultation is listening with a stethoscope to detect certain sounds.
C
Observation uses the eyes to look and visually examine the patient.
D
Olfaction involves smelling.

PTS: 1 REF: Chapter: 21 | Page: 425 OBJ: Chapter Objective: 21-4
KEY: Content Area: Health Promotion and Maintenance | Integrated Process: Nursing Process/Assessment | Client Need: Health Promotion and Maintenance/Data Collection Techniques | Cognitive Level: Comprehension

4. ANS: C

Feedback
A
Abnormal findings should be rechecked within 4 hours or sooner, but 15 minutes is too soon unless the blood pressure was critically elevated.
B
Abnormal findings should be rechecked within 4 hours or sooner.
C
Since the blood pressure was moderately elevated from 8 a.m. the blood pressure should be rechecked within 1 to 2 hours, even if that were the typical elevation in blood pressure for that patient. Chapter Objective: Explain the significance of abnormal assessment findings.
D
For a blood pressure that is now hypertensive, both systolic and diastolic will need to be rechecked.

PTS: 1 REF: Chapter: 21 | Page: 452 OBJ: Chapter Objective: 21-7
KEY: Content Area: Coordinated Care | Integrated Process: Communication and Documentation | Client Need: Safe and Effective Care Environment/Coordinated Care/Staff Education | Cognitive Level: Application

5. ANS: B

Feedback
A
Subjective data is a symptom of an illness or injury.
B
Signs of an illness or injury are measureable and objective. Chapter Objectie: Define key terms associated with physical assessment.
C
Symptoms are reported by the patient and are subjective.
D
Signs are findings that the nurse can observe or measure.

PTS: 1 REF: Chapter: 21 | Page: 423 OBJ: Chapter Objective: 21-1
KEY: Content Area: Coordinated Care | Category of Health Alteration: Staff Education | Integrated Process: Communication and Documentation | Client Need: Safe and Effective Care Environment/Coordinated Care/Staff Education | Cognitive Level: Application