Chapter 20: Health History and Physical Assessment

Chapter 20: Health History and Physical Assessment

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate?

ANS:  B

The important fact in this question is that the patient is partly undressed and the nurse provides a means to keep the patient warm. All answers are appropriate for any examination, but keeping the patient warm is specific to this situation.

DIF:    Applying        REF:   p. 334            OBJ:   20.2               TOP:   Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  Concepts: Communication

2. A patient wishes to review his medical record. What response by the nurse is best?

ANS:  C

Patients have the right to look at their records. It is best if a health care provider is present in order to answer any questions the patient may have or to help interpret any information found within the record.

DIF:    Applying        REF:   p. 335            OBJ:   20.2

TOP:   Integrated Process: Communication and Documentation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

3. A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best?

ANS:  B

For patient safety, some patients should never be left alone on an examination table: infants; small children; older adults who are confused, combative, or uncooperative, and people who are physically or chemically restrained. The nurse calls for another staff member to get the missing equipment. Getting up and down off the table is inconvenient and may be difficult. Finishing the exam and then retrieving the piece of equipment also involves the patient changing locations and is inconvenient for the patient.

DIF:    Applying        REF:   p. 335            OBJ:   20.2               TOP:   Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control          NOT:           Concepts: Safety, Clinical Judgment

4. A student nurse is preparing to auscultate a patient’s lungs. What action by the student leads the instructor to intervene?

ANS:  C

The diaphragm is used to listen to bowel sounds. The other actions are appropriate.

DIF:    Applying        REF:   p. 338            OBJ:   20.3               TOP:   Assessment

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  Concepts: Clinical Judgment