Bates’ Guide To Physical Examination and History Taking 13th Edition Bickley Test Bank CHAPTER 1 Foundations for Clinical Proficiency MULTIPLE CHOICE 1.
... [Show More] After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a . Objective. b . Reflective. c . Subjective. d . Introspective. ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a . Objective. b . Reflective. c . Subjective. d . Introspective. ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used WWW.THENURSINGMASTERY.COM contact: [email protected] to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. The patients record, laboratory studies, objective data, and subjective data combine to form the: a . Data base. b . Admitting data. c . Financial statement. d . Discharge summary. ANS: A Together with the patients record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patients record, laboratory studies, or data. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a . Immediately notify the patients physician. b . Document the sound exactly as it was heard. c . Validate the data by asking a coworker to listen to the breath sounds. d . Assess again in 20 minutes to note whether the sound is still present. ANS: C When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care WWW.THENURSINGMASTERY.COM 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a . Intuition. b . A set of rules. c . Articles in journals. d . Advice from supervisors. ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: General 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a . Intuition. b . The nursing process. c . Clinical knowledge. d . Diagnostic reasoning. ANS: A Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: General 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? WWW.THENURSINGMASTERY.COM a . EBP relies on tradition for support of best practices. b . EBP is simply the use of best practice techniques for the treatment of patients. c . EBP emphasizes the use of best evidence with the clinicians experience. d . The patients own preferences are not important with EBP. ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. DIF: Cognitive Level: Applying (Application) REF: p. 5 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a . Patient with postoperative pain b . Newly diagnosed patient with diabetes who needs diabetic teaching c . Individual with a small laceration on the sole of the foot d . Individual with shortness of breath and respiratory distress ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? WWW.THENURSINGMASTERY.COM a . Low self-esteem b . Lack of knowledge c . Abnormal laboratory values d . Severely abnormal vital signs ANS: C Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. Which critical thinking skill helps the nurse see relationships among the data? a . Validation b . Clustering related cues c . Identifying gaps in data d . Distinguishing relevant from irrelevant ANS: B Clustering related cues helps the nurse see relationships among the data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a Nursing . b Medical . WWW.THENURSINGMASTERY.COM c Admission . d Collaborative . ANS: A An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a Assessment, treatment, planning, evaluation, discharge, and follow-up . b Admission, assessment, diagnosis, treatment, and discharge planning . c Admission, diagnosis, treatment, evaluation, and discharge planning . d Assessment, diagnosis, outcome identification, planning, implementation, and . evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a . Breathing, pain, and sleep b . Breathing, sleep, and pain c . Sleep, breathing, and pain WWW.THENURSINGMASTERY.COM d Sleep, pain, and breathing . ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. Which of these would be formulated by a nurse using diagnostic reasoning? a . Nursing diagnosis b . Medical diagnosis c . Diagnostic hypothesis d . Diagnostic assessment ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: General 15. Barriers to incorporating EBP include: a . Nurses lack of research skills in evaluating the quality of research studies. b . Lack of significant research studies. c . Insufficient clinical skills of nurses. d . Inadequate physical assessment skills. ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. WWW.THENURSINGMASTERY.COM DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: General 16. What step of the nursing process includes data collection by health history, physical examination, and interview? a Planning . b Diagnosis . c Evaluation . d Assessment . ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2). DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2 MSC: Client Needs: General 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a . Form a committee to conduct research studies. b . Post published research studies on the units bulletin boards. c . Encourage the nurses to visit the library to review studies. d . Teach the nurses how to conduct electronic searches for research studies. ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. DIF: Cognitive Level: Applying (Application) REF: p. 6 WWW.THENURSINGMASTERY.COM MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a . Disease originates from the external environment. b . The individual human is a closed system. c . Nurses are responsible for a patients health state. d . Holistic health views the mind, body, and spirit as interdependent. ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. The nurse recognizes that the concept of prevention in describing health is essential because: a . Disease can be prevented by treating the external environment. b . The majority of deaths among Americans under age 65 years are not preventable. c . Prevention places the emphasis on the link between health and personal behavior. d . The means to prevention is through treatment provided by primary health care practitioners. ANS: C A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7 MSC: Client Needs: General 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: WWW.THENURSINGMASTERY.COM a . Patients history of allergies. b . Patients use of medications at home. c . Last menstrual period 1 month ago. d . 2 5 cm scar on the right lower forearm. ANS: D Objective data are the patients record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. DIF: Cognitive Level: Applying (Application) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a . A follow-up data base to evaluate changes at appropriate intervals b . An episodic data base because of the continuing, complex medical problems of this patient c . A complete health data base because of the nurses primary responsibility for monitoring the patients health d . An emergency data base because of the need to collect information and make accurate diagnoses rapidly ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the persons health care. DIF: Cognitive Level: Applying (Application) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 22. Which situation is most appropriate during which the nurse performs a focused or problemcentered history? WWW.THENURSINGMASTERY.COM a . Patient is admitted to a long-term care facility. b . Patient has a sudden and severe shortness of breath. c . Patient is admitted to the hospital for surgery the following day. d . Patient in an outpatient clinic has cold and influenza-like symptoms. ANS: D In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system. DIF: Cognitive Level: Applying (Application) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a . Collect a follow-up data base and then check her blood pressure. b . Ask her to read her health record and indicate any changes since her last visit. c . Check only her blood pressure because her complete health history was documented 2 months ago. d . Obtain a complete health history before checking her blood pressure because much of her history information may have changed. ANS: A A follow-up data base is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. DIF: Cognitive Level: Applying (Application) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a Collect history information first, then perform the physical examination and . institute life-saving measures. WWW.THENURSINGMASTERY.COM b . Simultaneously ask history questions while performing the examination and initiating life-saving measures. c . Collect all information on the history form, including social support patterns, strengths, and coping patterns. d . Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit. ANS: B The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a Identify the cause of his illness. . b Make accurate disease diagnoses. . c Provide cultural health rights for the individual. . d Provide culturally sensitive and appropriate care. . ANS: D The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care. CHAPTER 2 Evaluating Clinical Evidence MULTIPLE CHOICE 1. When performing a physical assessment, the first technique the nurse will always use is: a . Palpation. b . Inspection. c . Percussion. WWW.THENURSINGMASTERY.COM d Auscultation. . ANS: B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a . Usually yields little information. b . Takes time and reveals a surprising amount of information. c . May be somewhat uncomfortable for the expert practitioner. d . Requires a quick glance at the patients body systems before proceeding with palpation. ANS: B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a quick glance. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a . Fingertips; they are more sensitive to small changes in temperature. b . Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c . Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. WWW.THENURSINGMASTERY.COM d Palmar surface of the hand; this surface is the most sensitive to temperature . variations because of its increased nerve supply in this area. ANS: B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation. DIF: Cognitive Level: Applying (Application) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a . Palpation b . Inspection c . Percussion d . Auscultation ANS: A Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed? a . Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain. b . Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c . The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d . The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. WWW.THENURSINGMASTERY.COM ANS: D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first. DIF: Cognitive Level: Applying (Application) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 6. The nurse would use bimanual palpation technique in which situation? a . Palpating the thorax of an infant b . Palpating the kidneys and uterus c . Assessing pulsations and vibrations d . Assessing the presence of tenderness and pain ANS: B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation. DIF: Cognitive Level: Applying (Application) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a Turgor . b Texture . c Density . d Consistency . ANS: C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115 WWW.THENURSINGMASTERY.COM MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a Percussing once over each area . b Quickly lifting the striking finger after each stroke . c Striking with the fingertip, not the finger pad . d Using the wrist to make the strikes, not the arm . ANS: A For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. DIF: Cognitive Level: Applying (Application) REF: p. 116 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a Consider this a normal finding. . b Palpate this area for an underlying mass. . c Reposition the hands, and attempt to percuss in this area again. . d Consider this finding as abnormal, and refer the patient for additional treatment. . ANS: A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? WWW.THENURSINGMASTERY.COM a Ask the patient to take deep breaths to relax the abdominal musculature. . b Consider this finding as normal, and proceed with the abdominal assessment. . c Increase the amount of strength used when attempting to percuss over the . abdomen. d Decrease the amount of strength used when attempting to percuss over the . abdomen. ANS: C The thickness of the persons body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. DIF: Cognitive Level: Applying (Application) REF: p. 116 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4- year-old child. The nurse should: a Palpate over the area for increased pain and tenderness. . b Ask the child to take shallow breaths, and percuss over the area again. . c Immediately refer the child because of an increased amount of air in the lungs. . d Consider this finding as normal for a child this age, and proceed with the . examination. ANS: D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a childs lung. DIF: Cognitive Level: Applying (Application) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a Count the patients respirations. . WWW.THENURSINGMASTERY.COM b . Bilaterally percuss the thorax, noting any differences in percussion tones. c . Call for a chest x-ray study, and wait for the results before beginning an assessment. d . Inspect the thorax for any new masses and bleeding associated with respirations. ANS: B Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patients physical status. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a Slope of the earpieces should point posteriorly (toward the occiput). . b Although the stethoscope does not magnify sound, it does block out extraneous . room noise. c Fit and quality of the stethoscope are not as important as its ability to magnify . sound. d Ideal tubing length should be 22 inches to dampen the distortion of sound. . ANS: B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiners nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 116 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a Is used to listen for high-pitched sounds. . b Is used to listen for low-pitched sounds. . WWW.THENURSINGMASTERY.COM c Should be lightly held against the persons skin to block out low-pitched sounds. . d Should be lightly held against the persons skin to listen for extra heart sounds . and murmurs. ANS: A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held against the persons skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a Warm the endpiece of the stethoscope by placing it in warm water. . b Leave the gown on the patient to ensure that he or she does not get chilled . during the examination. c Ensure that the bell side of the stethoscope is turned to the on position. . d Check the temperature of the room, and offer blankets to the patient if he or she . feels cold. ANS: D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiners hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. DIF: Cognitive Level: Applying (Application) REF: p. 117 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a Palpation . b Inspection . WWW.THENURSINGMASTERY.COM c Percussion . d Auscultation . ANS: A Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a Is often used to direct light onto the sinuses. . b Uses a short, broad speculum to help visualize the ear. . c Is used to examine the structures of the internal ear. . d Directs light into the ear canal and onto the tympanic membrane. . ANS: D The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 119 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a . Using the large full circle of light when assessing pupils that are not dilated b . Rotating the lens selector dial to the black numbers to compensate for astigmatism c . Using the grid on the lens aperture dial to visualize the external structures of the eye WWW.THENURSINGMASTERY.COM d Rotating the lens selector dial to bring the object into focus . ANS: D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 119 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a . Auscultate over the area with a fetoscope. b . Use a goniometer to measure the pulsations. c . Use a Doppler device to check for pulsations over the area. d . Check for the presence of pulsations with a stethoscope. ANS: C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 120 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a . Performs the examination from the left side of the bed. b . Examines tender or painful areas first to help relieve the patients anxiety. c . Follows the same examination sequence, regardless of the patients age or condition. d . Organizes the assessment to ensure that the patient does not change positions too often. WWW.THENURSINGMASTERY.COM ANS: D The steps of the assessment should be organized to ensure that the patient does not change positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiners preference. Tender or painful areas should be assessed last. DIF: Cognitive Level: Applying (Application) REF: p. 121 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable? a . Appear unhurried and confident when examining him. b . Stay in the room when he undresses in case he needs assistance. c . Ask him to change into an examining gown and to take off his undergarments. d . Defer measuring vital signs until the end of the examination, which allows him time to become comfortable. ANS: A Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the persons vital signs, will gradually accustom the person to the examination. DIF: Cognitive Level: Applying (Application) REF: p. 121 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 22. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a . Washing ones hands after removing gloves is not necessary, as long as the gloves are still intact. b . Hands are washed before and after every physical patient encounter. c . Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d . Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. ANS: B The nurse should wash his or her hands before and after every physical patient encounter; after WWW.THENURSINGMASTERY.COM contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present. DIF: Cognitive Level: Applying (Application) REF: p. 120 MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control 23. The nurse is examining a patients lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a . Washing hands, and contacting the physician b . Continuing to examine the ulceration, and then washing hands c . Washing hands, putting on gloves, and continuing with the examination of the ulceration d . Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration ANS: C The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 120 MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control 24. During the examination, offering some brief teaching about the patients body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate? a . Your atrial dysrhythmias are under control. b . You have pitting edema and mild varicosities. c . Your pulse is 80 beats per minute, which is within the normal range. d . Im using my stethoscope to listen for any crackles, wheezes, or rubs. ANS: C The sharing of some information builds rapport, as long as the patient is able to understand the WWW.THENURSINGMASTERY.COM terminology. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 122 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 25. The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a . Examiner feel more comfortable and to gain control of the situation. b . Examiner to build rapport and to increase the patients confidence in him or her. c . Patient understand his or her disease process and treatment modalities. d . Patient identify questions about his or her disease and the potential areas of patient education. ANS: B Sharing information builds rapport and increases the patients confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 122 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 26. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a . When the infant is sleeping b . At the end of the examination c . Before auscultation of the thorax d . Halfway through the examination ANS: B The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 123 MSC: Client Needs: Safe and Effective Care Environment: Management of Care WWW.THENURSINGMASTERY.COM 27. When preparing to perform a physical examination on an infant, the nurse should: a . Have the parent remove all clothing except the diaper on a boy. b . Instruct the parent to feed the infant immediately before the examination. c . Encourage the infant to suck on a pacifier during the abdominal examination. d . Ask the parent to leave the room briefly when assessing the infants vital signs. ANS: A The parent should always be present to increase the childs feeling of security and to understand normal growth and development. The timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed, but a diaper should be left on a boy. DIF: Cognitive Level: Applying (Application) REF: p. 122 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 28. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a . Auscultate the lungs and heart while the infant is still sleeping. b . Examine the infants hips, because this procedure is uncomfortable. c . Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach. d . Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems. ANS: A When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures that should be performed at the end of the examination. DIF: Cognitive Level: Applying (Application) REF: p. 123 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 29. A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: WWW.THENURSINGMASTERY.COM a . Ask the parent to place the child on the examining table. b . Have the parent remove all of the childs clothing before the examination. c . Allow the child to keep a security object such as a toy or blanket during the examination. d . Initially focus the interactions on the child, essentially ignoring the parent until the childs trust has been obtained. ANS: C The best place to examine the toddler is on the parents lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time. DIF: Cognitive Level: Applying (Application) REF: p. 123 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 30. The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurses technique is most accurate? a . Asking questions enhances the childs autonomy b . Asking the child for permission helps develop a sense of trust c . This question is an appropriate statement because children at this age like to have choices d . Children at this age like to say, No. The examiner should not offer a choice when no choice is available ANS: D Children at this age like to say, No. Choices should not be offered when no choice is really available. If the child says, No and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, Shall I listen to your heart next or your tummy? CHAPTER 3 Interviewing and the Health History MULTIPLE CHOICE 1. The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, WWW.THENURSINGMASTERY.COM which statement does the nurse know to be most accurate? The woman is: a . Excited about her pregnancy but nervous about the labor. b . Exhibiting verbal and nonverbal behaviors that do not match. c . Excited about her pregnancy, but her husband is not and this is upsetting to her. d . Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this. ANS: B Communication is all behaviors, conscious and unconscious, verbal and nonverbal. All behaviors have meaning. Her behavior does not imply that she is nervous about labor, upset by her husband, or worried about the nurses response. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 28 MSC: Client Needs: Psychosocial Integrity 2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? a . Well-adjusted adolescent who came in for a sports physical b . Recovering alcoholic who came in for a basic physical examination c . Man whose wife has just been diagnosed with lung cancer d . Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him ANS: C The receiver attaches meaning determined by his or her experiences, culture, self-concept, and current physical and emotional states. The man whose wife has just been diagnosed with lung cancer may be experiencing emotions that affect his receiving. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 28 MSC: Client Needs: Psychosocial Integrity 3. The nurse makes which adjustment in the physical environment to promote the success of an interview? WWW.THENURSINGMASTERY.COM a . Reduces noise by turning off televisions and radios b . Reduces the distance between the interviewer and the patient to 2 feet or less c . Provides a dim light that makes the room cozy and helps the patient relax d . Arranges seating across a desk or table to allow the patient some personal space ANS: A The nurse should reduce noise by turning off the television, radio, and other unnecessary equipment, because multiple stimuli are confusing. The interviewer and patient should be approximately 4 to 5 feet apart; the room should be well-lit, enabling the interviewer and patient to see each other clearly. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. DIF: Cognitive Level: Applying (Application) REF: p. 29 MSC: Client Needs: Psychosocial Integrity 4. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a . Note-taking may impede the nurses observation of the patients nonverbal behaviors. b . Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c . Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d . Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. ANS: A The use of history forms and note-taking may be unavoidable. However, the nurse must be aware that note-taking during the interview has d [Show Less]