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HEALTH ASSESSMENT FINAL NURSING, NUR
HEALTH ASSESSMENT FINAL EXAM 2025|
QUESTIONS & ANSWERS|A+ RATED
The nurse is preparing to conduct a health history. Explain this to the patient. Answer- The purpose of a health 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: 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? "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? "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? "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: Mental illness. The review of systems provides the nurse with... 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
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? Alcohol can interact with all medications and make some diseases worse. Describe a genogram. 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?
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.. 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? "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? "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...
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: 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? 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:
Breast self-exams may detect lumps that appear between mammograms List risk factors for breast cancer 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? 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?
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct "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: 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:
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? 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? Examine your breast shortly after your menstrual period each month. Peau d'orange- 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-
Aneurysm- defect or sec formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect (aortic aneurysm) Dysphasia- Difficulty swallowing Anorexia- Loss of appetite Ascites abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer or portal hypertension Bruit-
blowing, swoishing sound her through a stethoscope when an artery is partially occluded Hepatomegaly- abnormally enlarged liver Paralytic ileus- complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction Peritonitis- inflammation of the peritoneum Nurse suspects a patient has a distended bladder. How should the nurse assess? Percuss and palpate the midline area above the suprapubic bone.
Percussion notes heard during the abdominal assessment may include: Tympany, hyperresonnance, and dullness. Causes of Abdominal Distention- Obesity, Ascites, Air or Gas, Ovarian cyst, Pregnancy, Tumor Before reporting silent bowel sounds, the nurse should listen for at least: 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: Examine the tender area first. State the rationale for performing auscultation of the abdomen before palpation or percussion.
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 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 occur before a meal or after meals, describe the pain is it a cramping, burning, dull, stabbing, or aching pain, are there any changes associated with meals does the pain become worse or better, what have you tried to relieve the pain, what makes the pain worse, is the pain associated with your menstrual cycle Right Upper Quadrant Organs- Liver, Gallbladder, Duodenum, Head of Pancreas, Right Kidney and adrenal gland, Hepatic flexure of colon, Part of ascending and transverse colon Left Upper Quadrant Organs-
How often, how much come up, color, odor, bloody, pain associated, any diarrhea, fever, chills, what did you eat in the last 24 hours, where, is there anyone else in the family with the same symptoms? Functional units of the musculoskeletal system- Joints Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: Ligaments To jump rope, the should has to be capable of: Circumduction Articulation of the mandible and temporal bone is: Temporomandibular joint
Palpation of the temporomandibular joint: Anterior to the tragus An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. How would you explain this to the patient? With aging, the vertebral column shortens The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. An action to prevent or delay bone loss in this group would be? Perform physical activity, such as fast walking. A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? Crepitation
