Exam 22: Assessing Health Status

A female patient of Asian descent was admitted to the medical-surgical unit with possible lung cancer. A male nurse is preparing to perform a physical assessment. It is best for the male nurse to:

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

To correctly determine the strength of a patient's lower extremities during a neurologic examination, the nurse asks the patient to:

An 8-year-old patient is due for height measurement during a routine examination. For an accurate measurement to be obtained, the child should be asked to stand with:

Before starting the initial morning care or the physical assessment of the patient, the first intervention the nurse would perform would be:

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

The nurse weighing an infant in an outpatient clinic should:

A nurse records absence of bowel sounds after assessing the abdomen in:

The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of:

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be placed on the:

The nurse lightly palpates the abdomen of a patient during a physical examination. On palpation to the right side of the abdomen, the patient cries out and draws the knees to the chest. The nurse should:

When the nurse asks the neurologically impaired patient to follow the motion of the nurse's fingers, the patient's eyes track the fingers with jerky movements, which should be documented as ________________.

The nurse who is assessing a patient for heart sounds anticipates that the S₂ sound (the "dub" sound") can be heard best at the ________ area.

Percussion is a technique by which the nurse can assess sounds relative to the underlying structures that indicate the presence of: (Select all that apply.)

The nurse is aware that the most accurate quick method to check hydration status in the elderly is to evaluate the moisture of the ______.

During a health interview, an elderly patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

To perform the Weber test, the tuning fork is struck and placed:

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

The nurse assessing a patient's capillary refill finds that it took 5 seconds for the color to return. The most appropriate intervention to do following this assessment is to: