Physical Examination and Health Assessment 8th Edition 0323510809
Chapter 28: The Complete Health Assessment: Adult Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. A hospitalized patient does not require a full neurologic examination during every shift
assessment. What is a method of assessing the neurologic status of a patient without performing a full neurological examination? a. Palpate the carotid pulse. b. Offer the patient a glass of water. c. Look at the significant other throughout the examination. d. Assign the nursing assistant to ask the patient questions and report the findings. ANS: B
Offering the patient water is not only a courtesy but also an opportunity for the nurse to note the following physical data: the patient’s ability to hear, follow directions, cross the midline, and swallow. Palpating the carotid pulse is a cardiovascular assessment. The nurse should make eye contact with the patient during assessments. Assessments are not within the scope of practice of a nursing assistant; the nurse cannot delegate assessments to a nursing assistant. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential 2. The examiner is assessing the extraocular muscles. Which of the following tests would be
inappropriate? a. Confrontation test b. Corneal light reflex c. Six cardinal positions of gaze d. Cranial nerve III, IV, and VI testing ANS: A
The confrontation test assesses cranial nerve II and visual fields, but not the extraocular muscles. Extraocular muscles can be tested by the corneal light reflex, the six cardinal positions of gaze, and by cranial nerve III, IV, and VI testing. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 3. What should the examiner do during auscultation of breath sounds? a. Listen with the bell of the stethoscope. b. Compare sounds on the left and right sides. c. Listen only to the posterior chest for adventitious sounds. d. Instruct the patient to breathe in and out through the nose. ANS: B
The examiner should auscultate the lungs from side to side to compare the breath sounds. The diaphragm of the stethoscope is used to assess lung sounds. The patient should be instructed to take deep breaths through the mouth during auscultation. Breath sounds should be auscultated on the anterior, lateral, and posterior chest.
Chapter 28 - The Complete Health Assessment Adult
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