NUR 2092 Health Assessment Final Nursing Final Exam
- 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
Answer Provided consistent informa- tion 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?
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?
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?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 1 / 4
Answer Mental illness.
- The review of systems provides the nurse with...
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?
Answer Patient denies any color change.
- The nurse is obtaining a history from a 30-year old male patient and is con- cerned about
health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
Answer "Do you perform testicular self-examinations?"
- Functional Assessment-- What information would you ask if the patient's leg was in a cast?
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 rela- tionships/resources, spiritual resources, coping and stress management, personal habits, environmental hazards, violence questions, and occupational health ques-
tions. 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 2 / 4
the reason why?
Answer Alcohol can interact with all medications and make some diseases worse.
- Describe a genogram.
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?
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..
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?
Answer "Are you able to dress yourself?"
- A patient is describing his symptoms to the nurse. Which of these state- ments reflects a
description of the setting of his symptoms?
Answer "This pain hap- pens 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...
Answer 3 / 4
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?
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
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?
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
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,
- / 4
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?