Ch30 Health Assessment & Physical Examination (Fundamentals)

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?

• Appearance and behavior

• Measurement of vital signs

• Observing specific body systems

• Conducting a detailed health history

Which number corresponds to the area of the chest where you would auscultate for the tricuspid valve?

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up?

• Auscultation of an apical heart rate of 76

• Absence of bowel sounds on abdominal assessment

• Respiratory rate of 8 breaths/min

• Palpation of dorsalis pedis pulses with strength of +2

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer?

• “I’ll make sure to schedule my colonoscopy annually after the age of 60.”

• “I’ll make sure to have a colonoscopy every 2 years.”

• “I’ll make sure to have a flexible sigmoidoscopy every year once I turn 55.”

• “I’ll make sure to have a fecal occult blood test annually once I turn 45.”

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.)

• Add salt to every meal.

• Talk with your health care provider about taking a daily low dose of aspirin

• Work with your health care provider to develop a regular exercise program

• Limit daily intake of fats to less than 25% to 35% of total calories

• Review strategies to encourage the patient to quit smoking.

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function:

Cranial Nerves

1. XII Hypoglossal

2. V Trigeminal

3. VI Adducens

4. IV Trochlear

5. X Vagus

Cranial Nerve Function

a. Motor innervation to the muscles of the jaw

b. Lateral movement of the eyeballs

c. Sensation of the pharynx

d. Downward, inward eye movements

e. Position of the tongue

The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching?

• “I’ll recognize abnormal lumps because they are very painful.”

• “I’ll start performing testicular self-examination monthly after I turn 15.”

• “I’ll perform the self-examination in front of a mirror.”

• “I’ll gently roll the testicle between my fingers.”

The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene?

• The student stands at a midline position behind the patient, observing for position of the spine and scapula.

• The student palpates the thoracic muscles for masses, pulsations, or abnormal movements.

• The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds

• The student places the palm of the hand over the intercostal spaces and asks the patient to say “ninety-nine.”

A patient has undergone surgery for a femoral artery bypass. The surgeon’s orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.)

• Place the fingers behind and below the medial malleolus.

• Have the patient slightly flex the knee with the foot resting on the bed

• Have the patient relax the foot while lying supine.

• Palpate the groove lateral to the flexor tendon of the wrist

• Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

The faith community nurse is teaching the community center women’s group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.)

• Menopause onset at the age of 49 years

• Family history with BRCA1 inherited gene mutation

• Age over 40 years

• Onset of menses before the age of 12

• Recent use of oral contraceptives

Tags

NGSS.HS-LS3-2