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 a. Confrontation test b. Corneal light reflex c. Six cardinal positions of gaze d. Cranial nerve III, IV, and VI testing

2. The examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate?

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 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.

3. What should the examiner do during auscultation of breath sounds?

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.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Middle-aged or older patient b. Pregnant patient with gestational diabetes c. Patient that reports abdominal pain d. Patient with enlarged, tender cervical lymph nodes

4. In which situation should the examiner auscultate for carotid bruits?

ANS: A

The examiner should auscultate for carotid bruits if the patient is middle-aged or older or shows symptoms or signs of cardiovascular disease.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Positive Romberg sign b. Positive Babinski sign c. Positive Ortolani sign d. Positive modified Allen test

5. When standing with their eyes closed, feet together, and arms at their sides, a patient sways and starts to fall. How should the nurse document this finding?

ANS: A

The Romberg test is an assessment of posture and balance (cerebellar function). Abnormal findings occur when the person sways, falls, or widens the base of the feet to avoid falling. A positive Romberg sign is loss of balance that occurs when closing the eyes and occurs with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A positive Babinski sign is an abnormal superficial reflex response. Ortolani sign tests hip stability. A modified Allen test is used to evaluate the adequacy of collateral circulation before cannulating the radial artery.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. The nurse pulls the pinna up and back. b. The nurse covers their lips to obscure them from view. c. The nurse asks the patient to repeat 3 letters or numbers. d. The nurse stands 4 feet away from the patient and whispers three different words.

6. The nurse is conducting a hearing screening. Which technique will the nurse use during the whisper test?

ANS: C

To assess hearing using the whisper test, the nurse should stand at arm’s length (2 feet) behind the person and test one ear at a time while masking hearing in the other ear. This is done by having the patient place one finger on the tragus and pushing it in and out of the auditory meatus. While the patient is doing this, the nurse should move their head about 2 feet away from the person’s ear and slowly whisper a set of 3 random numbers and letters. The nurse does not need to pull the pinna up and back or cover their lips as they should be standing behind the patient’s field of vision. The nurse should only stand 1 to 2 feet away, not 4 feet.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Listen with the bell. b. Listen with the diaphragm. c. Listen with both the diaphragm and bell working from apex to base in a Z pattern. d. Listen with both the bell and diaphragm comparing sides of the heart as progress from apex to base.

7. When auscultating heart sounds, which technique should the nurse use?

ANS: B

The nurse should auscultate the heart with the diaphragm of the stethoscope to study heart sounds, inching from the apex up to the base or vice versa in a rough “Z” pattern and then auscultate with the bell of the stethoscope again inching through all locations, noting any murmurs or abnormal sounds. The nurse should not be comparing “sides” but the sounds at the different sites (aortic, pulmonic, Erb’s point, tricuspid, and mitral).

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Say “ahh”. b. Stick out tongue. c. Smile and then frown. d. Follow the nurses fingers through the six cardinal positions of gaze.

8. The nurse is assessing the cranial nerves. To assess cranial nerve XII, what should the nurse ask the patient to do?

ANS: B

Cranial nerve XII is the hypoglossal nerve. To assess its function, the nurse should ask the patient to stick out his or her tongue and observe for the location (midline is normal) and any fasiculations. Having the patient say “ahh” assesses cranial nerve IX, having the patient smile and frown is assessing cranial nerve VII, and having the patient follow the nurses fingers through the six cardinal positions of gaze assesses cranial nerves III, IV, and VI.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Family history b. Personal history c. Past medical history d. History of present illness

9. When performing a health history, the nurse would note immunizations under which category?

ANS: C

Immunizations would be included in the past medical or health history. Immunizations would not be included in a family medical history, the personal/social history, or the history of present illness unless there was a health issue that included this type of medication administration.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Balance b. The spine c. Cervical range of motion d. External rotation of hips

10. While conducting a musculoskeletal assessment the nurse stands behind the patient and has the patient bend over and touch his or her toes. What is the nurse assessing?

ANS: B

Having a patient bend over and touch his or her toes while standing behind himself or herself, the nurse is observing the ROM of the spine and inspecting whether the spine is straight. This position does not assess balance, cervical range of motion, or external hip rotation.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Weber test b. Snellen test c. Confrontation test d. Corneal light reflex

11. The nurse is preparing to perform an examination of the eyes. Which test will the nurse conduct to assess the patient’s vision?

ANS: B

The Snellen eye chart is used to assess vision. The Weber test is a hearing test. Confrontation assesses a patient’s visual fields. The corneal light reflex assesses the parallel alignment of the eye axes by shining a light toward the person’s eye.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Use long, descriptive sentences to document findings. b. Record the data as soon as possible after the interview and physical examination. c. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient. d. If the information is not documented, then it can be assumed that it was done as a standard of care.

12. Which statement is true regarding the recording of data from the history and physical examination?

ANS: B

The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

Multiple Response

1. When gathering information relative to a complete health assessment, the nurse should include which in the decision-making process? (Select all that apply.)

a. Treat the health assessment as a legal document.

b. Use line drawings to explain and record pertinent findings.

c. Do not document findings on the computer while the patient is present.

d. Gather needed equipment before the start of the health assessment.

e. Write down “word for word” what the patient says as evidence of reliable documentation.

ANS: A, B, D

A prudent nurse gathers all needed equipment before the start of a complete health assessment. Simple line drawings can be used as illustrations of findings as well as teaching purposes during the health assessment interaction. Data from the history and physical examination should be recorded as soon as possible as memory fades as the day progresses. Documenting as you move through the examination works well for many examiners, but you just need to make you do not ignore the patient as you focus on the computer. The health assessment record is considered to be a legal document, and a prudent nurse proceeds cautiously to ensure its integrity is maintained. Although it is important to be accurate, it is virtually impossible to write down “word for word” everything that the patient may say during the assessment.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance