Chapter 07: Health Assessment

Chapter 07: Health Assessment

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse admits the patient with mild chest pain from the emergency department. Which should the nurse implement first to gain patient cooperation during a physical assessment?

a.	Explain the procedure and its purpose.
b.	Perform assessment in stages over the day.
c.	Complete assessment within 3 to 5 minutes.
d.	Assess painful areas before nontender areas.

 

 

ANS:  A

First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The information helps make the patient feel valued and important because the nurse engages him or her in the plan of care. In addition, the nurse reassures the patient about maintaining privacy. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. While the nurse will assesses painful and tender areas first because if pain is triggered, the nurse would want to stop the assessment and provide pain management, explaining the procedure should precede any assessment.. Assessment data are vital to manage pain successfully.

 

DIF:    Cognitive Level: Apply                   REF:   Page 156

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting pallor and a slight bluish color. Which should the nurse implement?

a.	Provide a warm heating pad.
b.	Collaborate with the healthcare provider.
c.	Assess patient oxygen saturation.
d.	Check for restricted venous return.

 

 

ANS:  C

Nail beds in a patient with light skin are a view of the patient’s capillary bed at the periphery. Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. Generally application of heat and cold requires a prescription from a healthcare provider; moreover, the nurse needs to assess the patient and gather related data before being able to decide that warmth is indicated. The nurse needs to complete the assessment first, as long as the patient is in no immediate danger or experiencing distress, and to think critically before collaboration. If collaboration with the provider becomes necessary, the nurse presents a complete patient assessment. Restricted venous return usually leads to edema; severe peripheral edema leads to pallor; and cyanosis potentially occurs but is not common.

 

DIF:    Cognitive Level: Apply                   REF:   Page 142, Table 7.2

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a level of consciousness within normal limits?

a.	States name, age, and date but not location
b.	Is lethargic; responds logically to questions
c.	Responds verbally, but words are unintelligible
d.	Responds to questions spontaneously; is alert and oriented

 

 

ANS:  D

The patient who responds to questions spontaneously and is alert and oriented exhibits neurological findings that are within normal limits. The patient is conscious, responds to the environment, and has congruent thought processes. The patient who does not know the location is disoriented to place. Lethargy is not a normal finding despite correct responses. Unintelligible speech is abnormal.

 

DIF:    Cognitive Level: Remember            REF:   Page 174| Page 176

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

4. How often should the nurse perform a general assessment of the patient?

a.	At least every 4 hours
b.	As often as it is needed
c.	When the patient requests it
d.	At the rate set by agency policy

 

 

ANS:  B

The nurse performs a general assessment at the beginning of the shift and as often as needed afterward; however, the nurse frequently performs a focused assessment to make clinical judgments and problem solve. Every 4 hours is time consuming unless indicated by patient condition. Patients do not determine when to perform an assessment, but the nurse is responsive to patient concerns and resolves the problem to the patient’s satisfaction. Agency policy generally requires an assessment at the beginning of the shift and supports the nurse’s decision to reassess the patient as needed at the nurse’s discretion.

 

DIF:    Cognitive Level: Remember            REF:   Page 130

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

5. The nurse is assessing a patient with a cast extending from just below the left knee to the toes. Which assessment contains a desirable patient outcome?

a.	The toes are pink bilaterally.
b.	The cast is warm at the ankle.
c.	Paresthesia is present in the left foot.
d.	The cast is snug at the knee.

 

 

ANS:  A

Bilateral pink toes indicate adequate oxygenation to the periphery and support the outcome, “Patient has pink and warm toes bilaterally while wearing cast.” This also implies that the cast fits properly without areas of constriction. An area of warmth on a cast potentially indicates an infection. Paresthesia indicates nerve compression or irritation; when this occurs with a cast in place on the affected extremity, it usually indicates swelling of the extremity, potentially leading to impaired perfusion. A tight cast potentially restricts blood flow and compresses nerves, leading to tissue damage and paresthesias.

 

DIF:    Cognitive Level: Analyze                REF:   Page 161

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment