chapter 7- beginning the physical examination
TRANSCRIPT
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1.Before completing the physical examination, the nurse determines that the patient is
awake, alert, and oriented. This information would be important for which part of the
general survey?A Apparent state of health
B !acial expression
" #evel of consciousness$ %osture, gait, motor activity, and speech
&.The nurse notes that a patient is grimacing. 'hat can the nurse ask the patient to
determine the cause of this facial expression?
A ($o you have a )uestion that you want to ask me?*
B ("an you tell me where you are experiencing pain?*" (Are you uncomfortable sitting in a chair?*
$ (Are you getting enough rest and sleep?*
+.$uring a general survey, the nurse asks if the patient is feeling cold. 'hat did the nurse
most likely observe in the patient?A The patient is wearing clothing that is inconsistent with warm weather.
B The patient is bouncing both legs up and down while seated.
" The patient is avoiding eye contact with the nurse.
$ The patients speech is slurred.
-.A patient has arrived to the clinic for a routine physical examination. %rior to assessingthe patients blood pressure, what should the nurse do?
A ake sure the arm selected is covered with clothing.B %alpate the radial artery to confirm a pulse is present." %osition the arm so that it is below waist level.
$ Ask the patient to sit )uietly in a chair for / minutes.
/.After assessing a patients radial pulse, the nurse determines that an apical pulse needs to
be assessed. 'hat will the nurse do when assessing the apical rate? 0elect all that apply.
A Assess the rate for 1 minute.B Assess the rate for +2 seconds and multiple by &.
" %lace the stethoscope at the apex of the heart.
$ %alpate the radial pulse while assessing the apical pulse.3 Ask the patient to sit )uietly for / minutes before assessing.
4.ince the nurse is unable to obtain an average5si6ed cuff to assess an adult patient with a
large arm, the nurse uses an oversi6ed cuff. 'hat blood pressure reading will the nurse
most likely obtain for this patient?
A "orrect readingB 7eading will be low
" 7eading will be high
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$ 7eading cannot be obtained
8.A patient had ingested hot coffee immediately after having an oral temperature reading
obtained of 1219!. The health care provider is asking for the temperature measurement to
be repeated using a tympanic membrane thermometer. 'hat temperature will the nursemost likely obtain using this different measurement route?
A 12&.-9!
B ::.49!" :;.49!
$ 12+.;9!
;.A patient recovering from abdominal surgery is complaining of pain. The nurse reali6es
that the patient is most likely experiencing which type of pain?
A %sychogenic
B <diopathic" =europathic
$ omatic
:.A patient recovering from a stroke complains of pain. The nurse suspects this patient is
most likely experiencing which type of pain?A =ociceptive
B =europathic
" omatic$ <diopathic
12.A patient rates the current pain level as being a / on the =umeric 7ating cale. >ow
should the nurse document this pain assessment?
A %atient experiencing a moderate amount of pain.B %atient experiencing mild pain.
" %atient rated pain level as being a / using the rating scale.
$ %atient stated (pain level not that bad.*
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Answer Key
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