Unit 1: Ch. 6 Assessment Flashcards
Which action by a patient marks the beginning of the physical assessment process?
a. Redressing after a physical examination
b. Breathing normally during auscultation
c. Greeting the nurse in the examination room
d. Sharing work environment information
Answer: c
Assessment begins at the moment the patient first interacts with the nurse. Redressing takes place at the end of the physical examination. Breathing during auscultation is part of the respiratory assessment and sharing health history and demographic information takes place during the patient interview.
Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.)
a. Distance between the chairs in which the nurse and patient are sitting
b. Traditional treatments typically used by the patient to treat disease
c. Gender preference for primary care providers (PCPs)
d. Physical condition of the patient
e. Music preference of the patient
Answers: a, b, c, d
The first four factors are important for the nurse to consider when initiating or conducting a patient interview. The distance that is comfortable for personal interaction and gender preferences for care providers are affected by cultural and age norms. During the interview, it is an important aspect of assessment to ask patients about the treatments that they traditionally use in response to illness. Preferred treatments sometimes can be incorporated into care plans. The physical condition of patients affects their ability to answer questions during an interview. It may be necessary to break the interview process into short periods to accommodate the patient who is seriously ill. Music preference is irrelevant before or during a patient interview. There should not be music playing during the interview because it would be a distraction.
Which action by the nurse is most appropriate during the orientation phase of the patient interview?
a. Always position patients in a comfortable reclined position to ensure their comfort during questioning.
b. Ask which name a patient prefers to be called during care to show respect and build trust.
c. Quickly conduct a review of systems to determine the need for a complete or focused assessment.
d. Begin with questions about intimacy and sexuality to address sensitive issues first.
Answer: b
The nurse should provide a personal introduction and establish the name by which the patient wants to be called at the very beginning of the interview as part of the orientation phase. In most cases, the patient and the nurse should be seated at eye level during the interview portion of the assessment. Questions about intimacy and sexuality should be reserved for later in the interview to establish rapport before exploring potentially sensitive issues. A review of systems takes place during the working phase of the nurse–patient interview, just before initiation of the physical assessment.
Which activity by the nurse best demonstrates part of the working phase of a patient interview? (Select all that apply.)
a. Summarizing previously discussed key topics
b. Including selected family members in care planning
c. Transferring care responsibilities to the home health nurse
d. Discussing health promotion activities that could be beneficial
Answer: b, d
Care planning takes place during the working phase of the nurse–patient interview. When a patient needs care assistance, it is important for family members who will be helping with the patient’s care to be involved in the process. Discussing potentially beneficial health promotion activities with a patient can also be done during the working phase. Summarizing key topics covered in the interview and transferring care responsibilities take place in the termination phase.
Which entry in a patient’s electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data?
a. Complaining of chest pain
b. Apical pulse 110
c. Comatose
d. Difficulty swallowing
Answer: c
Primary data are obtained from the patient directly. A patient who is comatose is unable to speak and therefore unable to share subjective, primary data. A patient complaining of chest pain has already shared primary, subjective data. A patient with an apical pulse of 110 who is alert or one who has difficulty swallowing may still be able to contribute subjective information to the data collection.
Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process?
a. “What do you do for a living? Can you describe your work environment?”
b. “Is there a family history of heart disease, cancer, high blood pressure, or stroke?”
c. “When was your last annual physical? What immunizations did you receive at that time?”
d. “Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?”
Answer: d
During a review of systems, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the review of systems.
Which cue by a patient can be validated by laboratory and diagnostic test results?
a. Deeply sighing with fatigue
b. Bilateral crackles in the lungs
c. Oxygen saturation of 98% on room air
d. 2+ pitting edema of the ankles and feet
Answer: a
A cue is a behavioral hint of a potential disease process or concern. In this case, the only cue is a deep sigh indicating fatigue. The level of fatigue can be verified by evaluating the patient’s hemoglobin and hematocrit levels for anemia. Crackles, oxygen saturation, and pitting edema are all physical assessment findings, not cues.
A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively?
a. Body systems model
b. Physical assessment model
c. Head-to-toe assessment model
d. Functional health patterns model
Answer: d
Job stress and family relationships data will only be recorded extensively when using the functional health patterns model. The functional health patterns model is holistic in its approach. The body systems model and head-to-toe assessment model focus on physical rather than psychological or emotional concerns. All three models listed are ways to organize physical assessment findings.
When initiating a physical examination, which action should the nurse take first?
a. Review of the patient’s prior medical records
b. Gather admission health history forms
c. Assess the patient’s vital signs
d. Perform light and deep palpation for fluid
Answer: c
Assessment of the patient’s vital signs begins the physical examination aspect of the assessment process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature. The nurse should review the patient’s prior medical records before the interview or after the patient interaction to fill in gaps. Admission health history forms need to be gathered before initiating the interview, and abdominal palpation takes place about halfway through the head-to-toe physical examination.
If the nurse discovers that a patient’s right elbow is swollen and painful during a physical examination, which action should the nurse take next?
a. Apply ice to decrease swelling and reduce pain
b. Percuss the area to determine the presence of fluid
c. Perform passive range of motion to promote flexibility
d. Inspect the patient’s left elbow to compare its appearance
Answer: d
A major aspect of assessment is checking for symmetry. If an abnormality is observed on one side of a patient’s body, the next step in the assessment is to compare that area with the other side. Applying ice is premature until the assessment is complete and an underlying cause of the swelling and pain is understood. Percussion is not indicated for assessment of a swollen elbow. Performing passive range of motion is not appropriate before identifying an injury or disease and determining its extent.
