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Health Assessment Final Nursing, NUR2092 Health Assessment Final Exam – Qs & As
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Health Assessment Final Nursing, NUR2092Health Assessment Final Exam – Qs & As
The nurse is preparing to conduct a health history. Explain this to the patient.
✔️Ans - 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: ✔️Ans - 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? ✔️Ans - "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? ✔️Ans - "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? ✔️Ans - "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: ✔️Ans - Mental
illness.
The review of systems provides the nurse with... ✔️Ans - 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? ✔️Ans - 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?
✔️Ans - "Do you perform testicular self-examinations?"
Functional Assessment-- What information would you ask if the patient's leg
was in a cast? ✔️Ans - 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? ✔️Ans - Alcohol can interact with all
medications and make some diseases worse.
Describe a genogram. ✔️Ans - 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? ✔️Ans -
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.. ✔️Ans - 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? ✔️Ans - "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? ✔️Ans - "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... ✔️Ans - 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? ✔️Ans - 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: ✔️Ans - 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? ✔️Ans - 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:
✔️Ans - 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? ✔️Ans - 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: ✔️Ans - Breast self-
exams may detect lumps that appear between mammograms
List risk factors for breast cancer ✔️Ans - 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? ✔️Ans - 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?
✔️Ans - 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: ✔️Ans - 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? ✔️Ans - Supine with the arms raised over the
head
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