Exam (elaborations)
NURS 2092 HEALTH ASSESSMENT EXAM QUESTIONS,ANSWERS WITH RATIONALLE 2022/2023
- Course
- Institution
NURS 2092 HEALTH ASSESSMENT EXAM QUESTIONS,ANSWERS WITH RATIONALLE 2022/2023
[Show more]
Seller
Follow
Expertsolutions
Reviews received
Content preview
NURS 2092 HEALTH ASSESSMENT EXAMQUESTIONS,ANSWERS WITH RATIONALLE 2022/2023
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 patient’s anxiety.
c.
Follows the same examination sequence, regardless of the patient’s age or
condition.
d.
Organizes the assessment to ensure that the patient does not change positions
too often.
RAT: 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 examiner’s preference. Tender or painful
areas should be assessed last.
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.
RAT: Anxiety can be reduced by an examiner who is confident, self-assured, considerate,
and unhurried. Familiar and relatively nonthreatening actions, such as measuring the
person’s vital signs, will gradually accustom the person to the examination.
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 one’s 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
, NURS 2092 HEALTH ASSESSMENT EXAM
QUESTIONS,ANSWERS WITH RATIONALLE 2022/2023
concern regarding the spread of infectious diseases.
RAT: The nurse should wash his or her hands before and after every physical patient
encounter; after 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.
The nurse is examining a patient’s 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
RAT: 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.
During the examination, offering some brief teaching about the patient’s body or the
examiner’s 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.
“I’m using my stethoscope to listen for any crackles, wheezes, or rubs.”
RAT: The sharing of some information builds rapport, as long as the patient is able to
understand the terminology.
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 patient’s 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.
RAT: Sharing information builds rapport and increases the patient’s confidence in the
examiner. It also gives the patient a little more control in a situation during which feeling
completely helpless is often present.
The nurse is examining an infant and prepares to elicit the Moro reflex at which time
during the examination?
, NURS 2092 HEALTH ASSESSMENT EXAM
QUESTIONS,ANSWERS WITH RATIONALLE 2022/2023
a. When the infant is sleeping
b.
At the end of the examination
c. Before auscultation of the thorax
d. Halfway through the examination
RAT: The Moro or startle reflex is elicited at the end of the examination because it may
cause the infant to cry.
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 infant’s vital signs.
RAT: The parent should always be present to increase the child’s 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.
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 infant’s 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.
RAT: 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.
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:
a. Ask the parent to place the child on the examining table.
b. Have the parent remove all of the child’s 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
child’s trust has been obtained.
RAT: The best place to examine the toddler is on the parent’s 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
, NURS 2092 HEALTH ASSESSMENT EXAM
QUESTIONS,ANSWERS WITH RATIONALLE 2022/2023
body part at a time.
The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?”
Which critique of the nurse’s technique is most accurate?
a. Asking questions enhances the child’s 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
RAT: 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?”
With which of these patients would it be most appropriate for the nurse to use games
during the assessment, such as having the patient “blow out” the light on the penlight?
a. Infant
b.
Preschool child
c. School-age child
d. Adolescent
RAT: When assessing preschool children, using games or allowing them to play with the
equipment to reduce their fears can be helpful. Such games are not appropriate for the
other age groups.
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this
age group?
a. Explain the procedures in detail to alleviate the child’s anxiety.
b.
Give the child feedback and reassurance during the examination.
c. Do not ask the child to remove his or her clothes because children at this age
are usually very private.
d. Perform an examination of the ear, nose, and throat first, and then examine the
thorax and abdomen.
RAT: With preschool children, short, simple explanations should be used. Children at this
age are usually willing to undress. An examination of the head should be performed last.
During the examination, needed feedback and reassurance should be given to the
preschooler.
When examining a 16-year-old male teenager, the nurse should:
a. Discuss health teaching with the parent because the teen is unlikely to be
interested in promoting wellness.
b. Ask his parent to stay in the room during the history and physical examination to
answer any questions and to alleviate his anxiety.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Expertsolutions. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $23.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
78252 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now