Health Assessment Final Nursing, NUR2092 Health Assessment Final Exam

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Health Assessment Final Nursing, NUR2092 Health Assessment Final Exam The nurse is preparing to conduct a health history. Explain this to the patient. Correct Answer: Answer- The purpose of a heal... th history is to provide a database of subjective information about the patient's past and current health history. You might say to the patient, "I will be asking you questions about your past and present health." This information will help the provider along with the physical exam (objective data) to develop a diagnosis or health status. The nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: Correct Answer: Provided consistent information and therefore is reliable A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? Correct Answer: "Can you point to where it hurts?" A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? Correct Answer: "How would you say the pain affects your ability to do your daily activities?" A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? Correct Answer: "Describe what happens (or the reaction) to you when you take Penicillin." The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: Correct Answer: Mental illness. The review of systems provides the nurse with... Correct Answer: Information regarding health promotion practices, the information helps to evaluate the past and present health state of each body system, to obtain any data that may have been omitted in the section about present illness, and to evaluate health promotion and teaching opportunities. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? Correct Answer: Patient denies any color change. The nurse is obtaining a history from a 30-year old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? Correct Answer: "Do you perform testicular self-examinations?" Functional Assessment-- What information would you ask if the patient's leg was in a cast? Correct Answer: A functional assessment includes the activities of daily living and the person's ability to take care of their needs. This area will help to formulate a nursing diagnosis. This could be present to the patient in a standardized form and will include data on the lifestyle and type of living environment. (Page 57) self-esteem, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, environmental hazards, violence questions, and occupational health questions. If a patient had a cast on their leg, appropriate questions would include how they transfer to bed, another chair, bathing technique, coping with the situation, support during the situation. Regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason why? Correct Answer: Alcohol can interact with all medications and make some diseases worse. Describe a genogram. Correct Answer: Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also highlight the health of close family members and more details such as communicable disease, environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the family history. The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? Correct Answer: Current health promotion activities. A 90-year-old patient tells the nurse that he cannot remember the names of the medication he is taking or why he is taking them. An appropriate response from the nurse would be.. Correct Answer: Would you have a family member bring in your medications please? The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? Correct Answer: "Are you able to dress yourself?" A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? Correct Answer: "This pain happens every time I sit down to use the computer." In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason why is... Correct Answer: This is the location for most breast tumors. In performing an assessment of a woman's elixir lymph system, the nurse should assess which of these nodes? Correct Answer: Central, lateral, pectoral, and subscapular. The breast has extensive lymphatic drainage, 75% of the drainage drains into the axillary nodes. There are groups of axillary nodes central, pectoral and subscapular. A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much". She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: Correct Answer: The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in sagging (flat and gabby) breasts. In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? Correct Answer: Explain that this is the result of hormonal changes (testosterone) and recommend a visit to their provider. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: Correct Answer: To seek more specific information about the pain, such as: When did you first notice it? Is the pain localized or all over? Is it painful to touch? Is the pain in relation to your menstrual cycle? Is the pain associated with activity or exercise? During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which questions would be important for the nurse to ask? Correct Answer: Where did the rash first appear- on the nipple, areola, or the surrounding skin? When did you first notice this? During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: Correct Answer: Breast self-exams may detect lumps that appear between mammograms List risk factors for breast cancer Correct Answer: History of breast cancer - family history—first-degree relative Medications such as estrogen and progestin combined Certain tumor suppressor genes called BRCA1 and BRCA2 (inherited mutation) Age During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? Correct Answer: Asymmetry isnot unusual, but the nurse should verify that this change is not new During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? Correct Answer: Whether the inversion is a recent change should be determined. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: Correct Answer: Slowly lift her arms above her head, and note any retraction or lag in movement. The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? Correct Answer: Supine with the arms raised over the head The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? Correct Answer: The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct Correct Answer: "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: Correct Answer: The decrease in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with borders that are not well defined. The nurse replies: Correct Answer: Because of the change in consistency of the lump, it should be further evaluated by the physician. The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is? Correct Answer: On the same day every month. During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most appropriate? Correct Answer: Examine your breast shortly after your menstrual period each month. Peau d'orange- Correct Answer: Lymphatic obstruction causes edema, which thickens the skin and exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer. Dullness- Correct Answer: A high-pitched muffled thud sound obtained by percussing over relatively dense organs such as liver or spleen, distended bladder, mass of adipose tissue Tympany- Correct Answer: A high-pitchedmusical and drum like note obtained by percussing the surface of a large air-containing space, such as the abdomen Resonance- Correct Answer: A low-pitched, clear, hollow note obtained by percussing over normal lung tissue Hyperresonnance- Correct Answer: A low-booming note obtained by percussing over the adult lungs that have increased air such as with a patient who has emphysema, present with distended abdomen Which structure is located in the left lower quadrant of the abdomen? Correct Answer: Sigmoid colon Aneurysm- Correct Answer: defect or sec formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect (aortic aneurysm) Dysphasia- Correct Answer: Difficulty swallowing Anorexia- Correct Answer: Loss of appetite Ascites Correct Answer: abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer or portal hypertension Bruit- Correct Answer: blowing, swoishing sound her through a stethoscope when an artery is partially occluded Hepatomegaly- Correct Answer: abnormally enlarged liver Paralytic ileus- Correct Answer: complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction Peritonitis- Correct Answer: inflammation of the peritoneum Nurse suspects a patient has a distended bladder. How should the nurse assess? Correct Answer: Percuss and palpate the midline area above the suprapubic bone. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: Correct Answer: Decreased gastric acid secretion. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: Correct Answer: Peritonitis, The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? Correct Answer: "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." Abdominal borborygmi- Correct Answer: Hyperactive bowel sounds Percussion notes heard during the abdominal assessment may include: Correct Answer: Tympany, hyperresonnance, and dullness. Causes of Abdominal Distention- Correct Answer: Obesity, Ascites, Air or Gas, Ovarian cyst, Pregnancy, Tumor Before reporting silent bowel sounds, the nurse should listen for at least: Correct Answer: 5 minutes The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: Correct Answer: Examine the tender area first. State the rationale for performing auscultation of the abdomen before palpation or percussion. Correct Answer: Percussion and palpation may increase peristalsis, which gives a false interpretation of bowel sounds Specific questions to ask a patient with abdominal pain for the past week Correct Answer: Describe the pain, is it in one spot, or does it move around, have the patient point to the area, when did it start, how long have you had the pain, is it constant or does it come and go, does it [Show More]

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