Chapter 22 Assessing Health Status

Chapter 22  Assessing Health Status

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:
a.
repeat the questions at the end of the visit to cross check for accuracy of data.
b.
reassure the patient that forgetfulness is a normal part of the aging process.
c.
gather information from a family member accompanying the patient.
d.
omit the interview and proceed to a physical examination.

ANS: C
If an older adult has difficulty with memory, data may be gathered from a family member or significant other.

DIF: Cognitive Level: Analysis REF: p. 376 OBJ: Theory #2
TOP: Data Collection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:
a.
admission to the unit.
b.
discharge.
c.
the beginning of each shift.
d.
the patient’s wakening in the morning.

ANS: C
A quick focused assessment should be performed on each patient at the beginning of each shift to monitor for subtle changes in condition. This assessment is not the full assessment done on admission.

DIF: Cognitive Level: Comprehension REF: p. 375
OBJ: Clinical Practice #2 TOP: Quick Focused Assessment
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:
a.
discontinue the examination and report findings to the primary care provider.
b.
palpate the abdominal skin 1.5 to 2 inches to determine the cause of pain.
c.
continue the examination and have the patient take deep breaths.
d.
proceed to percuss the abdomen with a quick snap of the wrist.

ANS: A
When palpating, the nurse should observe the patient’s face for signs of discomfort and discontinue palpations if they appear to cause pain.

DIF: Cognitive Level: Analysis REF: p. 380 OBJ: Theory #3
TOP: Physical Examination Techniques KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. When performing deep palpation, the nurse should:
a.
use one hand and exert pressure to depress tissue about one half to three fourths of an inch.
b.
use either one or two hands to depress the tissue about 1 inch.
c.
use either one or two hands to depress the tissue about 1.5 to 2 inches.
d.
use two hands and exert pressure to depress the tissue about 3 to 4 inches.

ANS: C
Deep palpation uses either hand to depress the tissue 1.5 to 2 inches.

DIF: Cognitive Level: Comprehension REF: p. 389 OBJ: Theory #3
TOP: Deep Palpation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. To the breath sounds of a patient correctly, the nurse should:
a.
inspect the chest wall for characteristics of movements and respirations.
b.
use a stethoscope and properly position the earpieces and diaphragm.
c.
percuss the chest by quickly tapping on the chest wall surface to produce sounds.
d.
touch the chest wall and note the texture, temperature, and moisture of the skin.

ANS: B
Auscultation requires properly placing the earpieces in the ears pointing forward toward the nose and using the diaphragm to auscultate for breath sounds.

DIF: Cognitive Level: Knowledge REF: p. 380
OBJ: Clinical Practice #2 TOP: Physical Assessment
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort