Nursing Health Assessment and Pain Practice Quiz 1

Answer: A – Auscultation immediately after inspection and then percussion and palpation

Explanation: With an abdominal assessment, auscultation always is performed before percussion and palpation because any abdominal manipulation, such as from palpation or percussion, can alter bowel sounds. Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last.

Answer: B – Client complaints of chest pain, dyspnea, or abdominal pain

Explanation: Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This potion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac, respiratory, and abdominal. The client’s name, address, age, and phone number are biographical data. A brief statement about what brought the client to the health care provider is the chief complaint. Information about the client’s sexual performance and preference addresses past health status.

Answer: D – “Is there anything else you would like to tell me?”

Explanation: By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Asking if the client understands what is happening is a yes-or-no question that can elicit little information.

Answer: D – 5 minutes

Explanation: To completely determine that bowel sounds are absent, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive at this conclusion.

Answer: D – Mitral area

Explanation: The mitral area (also known as the left ventricular area or the apical area), the fifth intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area is the second intercostal space to the left of the sternum. The tricuspid area is the fifth ICS to the left of the sternum.

Answer: B – The tail of Spence area must be included in self-examination

Explanation: The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. This area must also be included in breast self-examination. One half of all women who die of breast cancer are older than age 65. The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides, above head, and on the hips is also recommended. A pad is placed under the ipsilateral (e.g., same side) scapula of the breast being palpated.

Answer: C – The client continues normal growth and development with intact support systems.

Explanation: Even though the client may experience an aftermath phase, progress is still possible, as is effective rehabilitation. Aftermath reactions may occur but need not interfere with rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably would produce less pain tolerance.

Answer: B – Pain sensation is affected by a client’s anticipation of pain

Explanation: Phases of pain experience include the anticipation of pain. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Psychological factors contribute to a client’s pain perception. In many cases, pain results from emotions, such as hostility, guilt, or depression.

Answer: C – Control and distraction

Explanation: The mothers actions are example of control and distraction. Involving the child in care and providing distraction took his mind off the pain. Pharmacologic agents for pain analgesics — were not used. The home environment was not changed, and cutaneous stimulation, such as massage, vibration, or pressure, was not used.

Answer: C – These measures potentiate the effects of analgesics.

Explanation: Noninvasive measures may result in release of endogenous molecular neuropeptides with analgesics properties. They potentiate the effect of analgesics. No evidence indicates that noninvasive and nonpharmacologic measures are more effective than analgesics in relieving pain. Decreased input over large fibers allows more pain impulses to reach the central nervous system. There is no connection between type C fiber impulses and noninvasive and nonpharmacologic pain-control measures.