Chapter 30 Health Assessment and Physical Examination

Chapter 30 Health Assessment and Physical Examination NCLEX Style Questions 4.6 (15 reviews) Students also studied Terms in this set (40) Upmc Shadyside School of NursingN 110 Save Health Assessment NCLEX Question...119 terms smstraitPreview Exam 1 Health Assessment (Nclex Pr...51 terms Bri_PinaPreview Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview Physica 43 terms lizz A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene?

• "I will use the information from my assessment to figure

out if your antihypertensive medication is working effectively."

• "Nursing assessment data are used only to provide

information about the effectiveness of your medical care."

• "Nurses use data from their patient's physical

assessment to determine a patient's educational needs."

• "Information gained from physical assessment helps

nurses better understand their patients' emotional needs." B ("Nursing assessment date are used only to provide information about the effectiveness of your medical care.")

Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed?

• Running warm water over stethoscope for patient

comfort

• Cleaning stethoscope with Betadine
• Using alcohol-based hand disinfectant
• Cleaning stethoscope with alcohol

D (Cleaning stethoscope with alcohol) Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia?

• Prone position
• Sims' position
• Supine position
• Lateral recumbent

C (Supine position) During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?

• Applying water-based sunscreen only before

swimming

• Using tanning bed daily for 7 days before college

break trip

• Applying broad-spectrum sunscreen of SPF 5
• Taking extra precautions in the sun secondary to the

prescription D (Taking extra precautions in the sun secondary to the prescription) A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory tests would the nurse expect to be ordered?

• Liver function test
• Lead level
• Thyroid-stimulating hormone test
• Complete blood count

C (Thyroid-stimulating hormone test)

A febrile preschool-aged child presents to the after- hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicellar lesions as which type of skin lesion?

• Vesicle
• Wheal
• Papule
• Pustule

A (Vesicle) A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse's best next action is which of the following?

• Interviewing the patient in the presence of his/her

teacher

• Ignoring the findings because child abuse is a

declining problem

• Realizing that abuse victims usually report abusive

situations

• Contacting Social Services and reporting suspected

abuse D (Contacting Social Services and reporting suspected abuse) A nurse identifies Pediculosis humananus capitis.Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products?

• Fine-toothed comb
• Pediculicide
• Lindane-based shampoo
• Vinegar hair rinse

C (Lindane-based shampoo) A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Considering the visual acuity results, the nurse informs the parent that the child

• Should have an optometric examination.
• Is suffering from strabismus.
• May have presbyopia.
• Has vision issues most likely due to cataracts.

A (Should have an optometric examination)

During a routine pediatric history and physical, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required "every antibiotic under the sun" to cure him.Considering the neonatal history, the nurse determines that it is especially important to perform a focused _____ examination.

• Cardiac
• Respiratory
• Ophthalmic
• Hearing acuity

D (Hearing acuity) During a sexually transmitted illness presentation to high school students, the nurse recommends the HPV vaccine series to prevent

• Cervical cancer.
• Genital lesions.
• Vaginal discharge.
• Swollen perianal tissues.

A (Cervical cancer) A male student comes to the college health clinic. He hesitantly describes that his testis has lumps. The nurse recognizes this as a potential sign of which of the following?

• Inguinal hernia
• Sexually transmitted infection
• Testicular cancer
• Diuretic use

C (Testicular cancer) The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. The proper sequence for the nurse's initial assessment is

• Deep palpation, light palpation, inspection.
• Light palpation, deep palpation, inspection.
• Inspection, light palpation.
• Auscultation, deep palpation, light palpation.

C (Inspection, light palpation) The nurse is caring for a female victim of rape. To perform the proper evaluation, the nurse should place the patient in which of the following positions?

• Sitting
• Dorsal recumbent
• Lithotomy
• Knee-chest

C (Lithotomy)