Lewis: Medical-Surgical Nursing, 7th Edition

Test Bank

Chapter 4: Health History and Physical Examination

MULTIPLE CHOICE

1. A patient having difficulty breathing is admitted to the hospital. The best approach for
the nurse to use to obtain a complete health history is to
a. use the health care provider’s medical history to obtain subjective data.
b. obtain subjective data about the patient from family members.
c. delay subjective data collection and focus only on the physical examination.
d. schedule several short sessions with the patient to gather subjective data.

Correct Answer: D
Rationale: In an emergency situation, the nurse may need to ask only the most pertinent
questions for a specific problem and obtain more information later. A complete health
history will include subjective information that is not available in the health care
provider’s medical history. Family members may be able to give some subjective data,
but only the patient will be able to give subjective information about the shortness of
breath. The physical examination will not provide a complete health history.

Cognitive Level: Application Text Reference: p. 40

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

2. When the nurse is gathering information of a personal nature, the question that best
communicates acceptance of the patient is,
a. “Individuals going through a divorce have many emotional problems. What kind of
problems are you having?”
b. “Many older people have limited financial resources for food and medications. Is
this a problem in your case?”
c. “A lot of people drink alcohol in excessive amounts. How much alcohol do you
drink in a day?”
d. “Many drugs used for hypertension cause sexual dysfunction. What type of
problems are you having?”

Correct Answer: B

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 4-2

Rationale: When asking personal or potentially sensitive questions, prefacing the

question with phrases such as “many people” indicates that the patient’s situation is
normal. Therefore, the best response is that where the nurse asks whether the patient
actually has the problem of limited resources but does not imply any judgments about the
patient in his regard. The response beginning, “Individuals going through a divorce have
many emotional problems” implies that the nurse has already decided the patient must be
having emotional problems. The response beginning, “A lot of people drink alcohol in
excessive amounts” indicates that the nurse thinks the patient does drink alcohol daily.
And the response beginning, “Many drugs used for hypertension cause sexual
dysfunction” indicates that the nurse is sure that the patient is having problems.

Cognitive Level: Application Text Reference: p. 41

Nursing Process: Assessment NCLEX: Psychosocial Integrity

3. A patient is admitted to the orthopedic unit with a fractured right elbow following a
skiing accident. During the initial nursing assessment, the subjective information the
nurse obtains from the patient about how the injury occurred and what treatments
have been implemented is related to the functional health pattern of
a. activity-exercise.
b. cognitive-perceptual.
c. health perception-health maintenance.
d. self-perception–self-concept.

Correct Answer: C
Rationale: In a hospitalized patient, the health perception-health maintenance pattern
includes information about the patient’s understanding of the onset and treatment of the
current health problem. The activity-exercise pattern will include questions about how
often the patient skis. The cognitive-perceptual pattern question may address how much
pain the patient is experiencing. The self-perception–self-concept pattern may include
questions such as how skiing impacts the patient’s self-concept.

Cognitive Level: Application Text Reference: pp. 44-45

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

4. Immediate surgery is planned for a patient with acute abdominal pain. The question
used by the nurse that will elicit the most complete information about the patient’s
coping-stress tolerance pattern is
a. “What do you think caused this abdominal pain?”
b. “Are there any other major problems that are a concern right now?”
c. “How do you feel about yourself and your hospitalization?”
d. “Can you tell me how intense your pain is now?”

Correct Answer: B

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 4-3

Rationale: The coping-stress tolerance pattern includes information about other major
stressors confronting the patient. The health perception-health management pattern
includes information about the patient’s ideas about risk factors. Feelings about self and
the hospitalization are assessed in the self-perception–self concept pattern. Intensity of
pain is part of the cognitive-perceptual pattern.

Cognitive Level: Application Text Reference: pp. 45-46

Nursing Process: Assessment NCLEX: Psychosocial Integrity

5. During the health history interview, a patient tells the nurse about periodic fainting
spells. In gathering more specific information, the question that will best assist in
determining the setting where the fainting spells occur is,
a. “Do the spells tend to occur at any special time of day?”
b. “How frequently do you have the fainting spells?”
c. “Where are you when you have the fainting spells?”
d. “Do you have any other symptoms along with the spells?

Correct Answer: C
Rationale: Information about the setting is obtained by asking where the patient was and
what the patient was doing when the symptom occurred. The other questions from the
nurse are appropriate for obtaining information about chronology, frequency, and
associated clinical manifestations.

Cognitive Level: Application Text Reference: p. 41

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

6. The nurse records the following general survey of a patient: “The patient is a 68-year-
old male Asian attended by his wife and two daughters. Alert and oriented. Does not
make eye contact with the nurse and responds slowly, but appropriately, to questions.
No apparent disabilities or distinguishing features.” Additional information that
should be added to this general survey includes
a. reasons for contact with the health care system.
b. comments of family members about his condition.
c. nutritional status.
d. intake and output.

Correct Answer: C
Rationale: The general survey also describes the patient’s general nutritional status. The
other information will be obtained when doing the complete nursing history and
examination but is not obtained through the initial scanning of a patient.

Cognitive Level: Application Text Reference: p. 46

Nursing Process: Assessment

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 4-4

NCLEX: Health Promotion and Maintenance

7. Following knee surgery, the patient has an elastic bandage applied to the surgical site.
When assessing the circulation to the lower leg, the first action the nurse will take is
to
a. visually inspect the color of the foot.
b. palpate the temperature of the foot.
c. use a stethoscope to auscultate ankle blood pressure.
d. check the patient’s pedal pulses using the fingertips.

Correct Answer: A
Rationale: Inspection is the first of the major techniques used in the physical
examination. Palpation and auscultation are used later in the examination.

Cognitive Level: Application Text Reference: p. 47

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

8. All the following information is obtained by the nurse while performing a health
history and physical examination from a patient with right-sided rib fractures. The
pertinent negative finding is that the patient
a. states that there have been no other health problems recently.
b. refuses to take a deep breath because of the associated chest pain.
c. has several bruised and swollen areas on the right anterior chest.
d. denies having pain when the area over the fractures is palpated.

Correct Answer: D
Rationale: The nurse expects that a patient with rib fractures will have pain over the
fractured area. The first statement is neither a positive nor a negative finding with regard
to the rib fractures. The pain with breathing and the bruising and swelling are positive
findings.

Cognitive Level: Application Text Reference: p. 47

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

9. As the nurse assesses the patient’s neck, the patient says, “My neck is so stiff I can
hardly move it.” This finding indicates the nurse should perform a(n)
a. specific examination.
b. screening examination.
c. focused examination.
d. extensive examination.

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

 Test Bank 4-5

Correct Answer: C
Rationale: The focused examination is needed when a patient has clinical manifestations
that indicate a problem. The term specific examination is not a commonly used term. The
screening examination is a general check to determine any possible problems. Extensive
examination is another term that is not generally used and would not be clearly
understood by other members of the health care team.

Cognitive Level: Comprehension Text Reference: p. 47

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

10. In performing a physical examination, it is most important for the nurse to use
a. the head-to-toe approach.
b. a consistent, systematic approach.
c. the body-systems model.
d. a model based on a nursing theory.

Correct Answer: B
Rationale: The nurse is less likely to omit a needed part of the examination if a
consistent approach is followed every time. Either a head-to-toe approach or a body-
systems approach may be used. Nursing theories do not describe the approach to the
physical examination.

Cognitive Level: Comprehension Text Reference: p. 48

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

11. The nurse is preparing to perform a screening physical examination for a patient. The
assessment technique that will require a stethoscope is
a. inspection.
b. percussion.
c. auscultation.
d. palpation.

Correct Answer: C
Rationale: A stethoscope is used to auscultate sounds produced by various parts of the
body. Inspection, percussion, and palpation do not require a stethoscope.

Cognitive Level: Knowledge Text Reference: p. 48

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

 Test Bank 4-6

12. Adaptations used by the nurse when performing a physical examination on an 86-
year-old patient will include
a. avoiding the use of touch as much as possible.
b. organizing the sequence to minimize position changes.
c. using slightly more pressure for palpation of the liver.
d. speaking slowly when directing the patient.

Correct Answer: B
Rationale: Older patients may have age-related changes in mobility that make it more
difficult to change position. There is no need to avoid the use of touch when examining
older patients. Less pressure should be used over the liver. There is no indication that the
patient has any age-related difficulty in understanding directions from the nurse.

Cognitive Level: Application Text Reference: p. 50

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

13. While the nurse is taking the health history, a patient states, “My father and
grandfather both had heart attacks and were unable to be very active afterwards.” This
statement is related to the functional health pattern of
a. health perception-health management.
b. activity-exercise.
c. cognitive-perceptual.
d. coping-stress tolerance.

Correct Answer: A
Rationale: The information in the patient statement relates to risk factors that may cause
cardiovascular problems in the future. Identification of risk factors falls into the health
perception-health maintenance pattern.

Cognitive Level: Application Text Reference: p. 44

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

14. The nurse is admitting a patient who has just arrived on the medical-surgical unit with
severe abdominal pain. The action by the nurse that will be most effective in
obtaining complete and accurate data from the patient is
a. to complete only basic demographic data before addressing the patient’s abdominal
pain.
b. to inform the patient that the abdominal pain will be treated as soon as the health
history is completed.
c. to take the initial vital signs and then deal with the abdominal pain prior to
completing the health history.
d. to medicate the patient for the abdominal pain before attending to the health

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

 Test Bank 4-7

history and examination.

Correct Answer: C
Rationale: The patient priority in this situation will be to decrease the pain level, so the
patient will be unlikely to cooperate in providing demographic data or the health history
until the nurse addresses the pain. However, obtaining information about vital signs is
essential before using either pharmacologic or nonpharmacologic therapies for pain
control. The vital signs may indicate hemodynamic instability which would need to be
addressed immediately.

Cognitive Level: Application Text Reference: p. 41

Nursing Process: Assessment NCLEX: Physiological Integrity

15. A patient is seen in the emergency department with acute nausea and vomiting. The
nurse obtains information about the length of time that the patient has been nauseated,
the approximate amount of the emesis, and performs a physical assessment of the
patient’s abdomen. This will be described as a/an
a. comprehensive database.
b. episodic assessment.
c. follow-up database.
d. subjective assessment.

Correct Answer: B
Rationale: An assessment that is focused on a problem of limited scope is called an
episodic (or problem-focused) assessment and is used when the intention is to identify
and treat a specific patient problem. A comprehensive database includes all detailed
information about multidimensional aspects of the patient’s health. A follow-up database
is used to evaluate the status of a previously identified problem. Subjective assessments
are an important aspect of all types of databases.

Cognitive Level: Comprehension Text Reference: p. 40

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.