Test Bank for Bates’ Guide to Physical Examination and History Taking, 12th Edition

Chamberlain College Of Nursing

FNP 509

Physical Examination

Chapter 1: Overview: Physical Examination and History Taking

Multiple Choice

1.    For which of the following patients would a comprehensive health history be appropriate?

A)    A new patient with the chief complaint of “I sprained my ankle”

B)    An established patient with the chief complaint of “I have an upper respiratory infection”

C)    A new patient with the chief complaint of “I am here to establish care”

D)    A new patient with the chief complaint of “I cut my hand”

Ans: C Chapter: 01

Page and Header: 4, Patient Assessment: Comprehensive or Focused

Feedback: This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate.

2.    The components of the health history include all of the following except which one?

A)    Review of systems

B)    Thorax and lungs

C)    Present illness

D)    Personal and social items

Ans: B Chapter: 01

Page and Header: 4, Patient Assessment: Comprehensive or Focused

Feedback: The thorax and lungs are part of the physical examination, not part of the health history. The others answers are all part of a complete health history.

3.    Is the following information subjective or objective?

Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest.

A)    Subjective

B)    Objective

Ans: A Chapter: 01

Page and Header: 6, Differences Between Subjective and Objective Data

Feedback: This is information given by the patient about the circumstances of his chief complaint. It does not represent an objective observation by the examiner.

4.    Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120.

A)    Subjective

B)    Objective

Ans: B Chapter: 01

Page and Header: 6, Differences Between Subjective and Objective Data

Feedback: This is a measurement obtained by the examiner, so it is considered objective data. The patient is unlikely to be able to give this information to the examiner.

5.    The following information is recorded in the health history: “The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid- epigastric area.”

Which of these categories does it belong to?

A)    Chief complaint

B)    Present illness

C)    Personal and social history

D)    Review of systems

Ans: B Chapter: 01

Page and Header: 6, The Comprehensive Adult Health History

Feedback: This information describes the problem of abdominal pain, which is the present illness. The interviewer has obtained the location, timing, severity, and associated manifestations of the pain. The interviewer will still need to obtain information concerning the quality of the pain, the setting in which it occurred, and the factors that aggravate and alleviate the pain. You will notice that it does include portions of the pertinent review of systems, but because it relates directly to the complaint, it is included in the history of present illness.

6.    The following information is recorded in the health history: “The patient completed 8th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week.”

Which category does it belong to?

A)    Chief complaint

B)    Present illness

C)    Personal and social history

D)    Review of systems

Ans: C Chapter: 01

Page and Header: 6, The Comprehensive Adult Health History

Feedback: Personal and social history information includes educational level, family of origin, current household status, personal interests, employment, religious beliefs, military history, and lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual preferences and history). All of this information is documented in this example.

7.    The following information is recorded in the health history: “I feel really tired.” Which category does it belong to?

A)    Chief complaint

B)    Present illness

C)    Personal and social history

D)    Review of systems

Ans: A Chapter: 01

Page and Header: 6, The Comprehensive Adult Health History

Feedback: The chief complaint is an attempt to quote the patient's own words, as long as they are suitable to print. It is brief, like a headline, and further details should be sought in the present illness section. The above information is a chief complaint.

8.    The following information is recorded in the health history: “Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.”

Which category does it belong to?

A)    Chief complaint

B)    Present illness

C)    Personal and social history

D)    Review of systems

Ans: D Chapter: 01

Page and Header: 6, The Comprehensive Adult Health History

Feedback: Review of systems documents the presence or absence of common symptoms related to each major body system. The absence of cardiac symptoms is listed in the above example.

9.    The following information is best placed in which category? “The patient has had three cesarean sections.”

A)    Adult illnesses

B)    Surgeries

C)    Obstetrics/gynecology

D)    Psychiatric

Ans: B Chapter: 01

Page and Header: 9, Past History

Feedback: A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the time of the surgery should also be recorded.

10.    The following information is best placed in which category?

“The patient had a stent placed in the left anterior descending artery (LAD) in 1999.”

A)    Adult illnesses

B)    Surgeries

C)    Obstetrics/gynecology

D)    Psychiatric

Ans: A Chapter: 01

Page and Header: 9, Past History

Feedback: The adult illnesses category is reserved for chronic illnesses, significant hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but does not involve a surgeon.

11.    The following information is best placed in which category?

“The patient was treated for an asthma exacerbation in the hospital last year; the patient has

never been intubated.”

A)    Adult illnesses

B)    Surgeries

C)    Obstetrics/gynecology

D)    Psychiatric

Ans: A Chapter: 01

Page and Header: 9, Past History

Feedback: This is information about a significant hospitalization and should be placed in the adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider placing this information in the present illness section, because it relates to the chief complaint at that visit.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings

Multiple Choice

1.    A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to?

A)    Musculoskeletal

B)    Reproductive

C)    Urinary

D)    Endocrine

Ans: A Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: Chest pain may be due to a musculoskeletal condition, such as costochondritis or intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest pain is also a sharp chest pain which increases with a deep breath. This type of pain can occur with inflammation of the pleura from pneumonia or other conditions and pulmonary embolus.

2.    A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom?

A)    Reproductive

B)    Urinary

C)    Cardiac

D)    Hematologic

Ans: C Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: Cardiac disorders such as congestive heart failure are the most likely on this list to result in shortness of breath. There are cases within the other categories which may also result in shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive category, or sepsis with UTI in the urinary category. This demonstrates the “tension” in clinical reasoning between making sure all possibilities are covered, while still being able to pick the most likely cause.

3.    A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough?

A)    Ophthalmologic

B)    Auditory

C)    Cardiac

D)    Endocrine

Ans: C Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: The cardiac system can cause a cough if the patient has congestive heart failure. This results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch of the vagus nerve, but this is less likely to be seen clinically than heart failure.

4.    A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct?

A)    Infectious

B)    Inflammatory

C)    Hematologic

D)    Traumatic

Ans: B Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: The description is most consistent with an inflammatory process, although all the other etiologies should be considered. Lyme disease is an infection which commonly causes arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and trauma can obviously cause joint pain. Your clinical reasoning skills are important for sorting through all of the data to arrive at the most likely conclusion.

5.    A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for several years. He normally takes over-the-counter medications to ease the pain, but this time they haven't worked as well, and he still has discomfort. He recently wallpapered the entire second floor in his house, which caused him great discomfort. The pain resolved with rest. He denies fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this description, what is the most likely pathologic process?

A)    Infectious

B)    Neoplastic

C)    Degenerative

D)    Traumatic

Ans: C Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: The description is most consistent with degenerative arthritis in the neck. The patient has had intermittent symptoms and the questions asked to elicit pertinent negative and positive findings are negative for infectious, traumatic, or neoplastic disease.

6.    A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process?

A)    Infection

B)    Inflammation

C)    Allergic

D)    Vascular Ans: C

Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: This description is most consistent with allergic rhinitis.

7.    A 19-year-old-college student presents to the emergency room with fever, headache, and neck pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of her dorm mates have been vaccinated, but she hasn't been. Which of the following physical examination descriptions is most consistent with meningitis?

A)    Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of motion

B)    Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right

C)    Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion

D)    Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion

Ans: C Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused by meningeal inflammation. Later, you will learn about Kernig's and Brudzinski's signs, which are helpful in testing for meningeal irritation on examination.

8.    A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods. Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis?

A)    Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses.

B)    Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or guarding.

C)    Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding.

D)    Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or guarding.

Ans: C Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: In cholecystitis, the pain, which originates from the gallbladder, is located in the right upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is also known as Murphy's sign, which, if present, is further indicative of inflammation of the gallbladder.

9.    A 55-year-old data entry operator comes to the clinic to establish care. She has the following symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained by:

A)    One disease process

B)    More than one disease process

Ans: B Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: The patient appears to have several possible conditions: allergic rhinitis, arthritis, conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous stasis, among other conditions. Although we always try, it is very difficult to assign all of these symptoms to one cohesive diagnosis.

10.    A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever, headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of symptoms is best explained by:

A)    One disease process

B)    More than one disease process

Ans: A Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: This cluster of symptoms is most consistent with sinusitis. The chance that all of these symptoms are caused by multiple synchronous conditions in the same patient is much less than the possibility of having one problem which accounts for all of them.

11.    Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient's family history is positive for asthma. You think the child most likely has asthma. What have you just accomplished?

A)    You have tested your hypothesis.

B)    You have developed a plan.

C)    You have established a working diagnosis.

D)    You have created a hypothesis.

Ans: D Chapter: 02

Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: As you go through a history and examination, you will start to generate ideas to explain the patient's symptoms. It is best to keep an open mind and make as many hypotheses as you can, to avoid missing a possibility. A common mistake is to latch onto one idea too early.

Once you have committed your mind to a diagnosis, it is difficult to change to another. To think about looking for wheezes on examination would be an example of testing your new hypothesis. Starting a patient on an inhaled medicine would be a plan. It is too early to commit to a working diagnosis, given the amount of information you have gathered.

12.    Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of shortness of breath and not being able to sleep in a flat position (orthopnea). On examination you note increased jugular venous pressure, an S₃ gallop, crackles low in the lung fields, and swollen ankles (edema). This is an example of a:

A)    Pathophysiologic problem

B)    Psychopathologic problem

Ans: A Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: This is an example of a pathophysiologic problem because Ms. Washington's symptoms are consistent with a pathophysiologic process. The heart attack reduced the ability of her heart to handle her volume status and subsequently produced the many features of congestive heart failure.

13.    On the way to see your next patient, you glance at the calendar and make a mental note to buy a Mother's Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her husband in May, two years ago. She comes in today with a headaches, abdominal pain, and general malaise. This happened once before, about a year ago, according to your detailed office notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie these symptoms together. This is an example of a:

A)    Pathophysiologic problem

B)    Psychopathologic problem

Ans: B Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: It is not uncommon for patients to experience psychopathologic symptoms around the anniversary of a traumatic event. The time of year and the lack of an obvious connection between Ms. Hernandez's symptoms would make you consider this as a possibility. You will note that although this might have been an early consideration in your hypothesis generation, it is key to convince yourself that there is not a physiologic explanation for these symptoms, by performing a careful history and examination.

14.    Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a sales office to support his family. Recently he has injured his back and you are thinking he would benefit from physical therapy, three times a week, for an hour per session. What would be your next step?

A)    Write the physical therapy prescription.

B)    Have your office staff explain directions to the physical therapy center.

C)    Discuss the plan with Mr. Larson.

D)    Tell Mr. Larson that he will be going to physical therapy three times a week.

Ans: C Chapter: 02

Page and Header: 30, Develop a Plan Agreeable to the Patient

Feedback: You should discuss your proposed plan with the patient before implementing it. In this case, you and Mr. Larson will need to weigh the benefit of physical therapy against the ability to provide for his family. You may need to consider other ways of helping the patient, perhaps through prescribed back exercises he can do at home. It is a common mistake to implement a plan without coming to an agreement with the patient first.

15.    You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain under his sternum. What would the order of priority be for your problem list?

A)    Arthritis, war injury pain, headaches, chest pain

B)    War injury pain, arthritis, headaches, chest pain

C)    Headaches, arthritis, war injury pain, chest pain

D)    Chest pain, headaches, arthritis, war injury pain

Ans: D Chapter: 02

Page and Header: 37, Generating the Problem List

Feedback: The problem list should have the most active and serious problem first. This new

complaint of chest pain is almost certainly a higher priority than his other, more chronic problems.

16.    You are excited about a positive test finding you have just noticed on physical examination of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only to find that there is no sign of the disease you thought would correlate with the finding. This same experience happens several times. What should you conclude?

A)    Consider not doing this test routinely.

B)    Use this test when you have a higher suspicion for a certain correlating condition.

C)    Continue using the test, perhaps doing less laboratory work and diagnostics.

D)    Omit this test from future examinations.

Ans: C Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: This is an example of a sensitive physical finding that lacks specificity. This does not make this a useless test, because the purpose of a screening physical is to find disease. This finding made you consider the associated condition as one of your hypotheses, and this in itself has value. Other possibilities are that you may be doing the maneuver incorrectly or using it on the wrong population. It is important to ask for hands-on help from your instructor when you have a question about a maneuver. Make sure that your information about the maneuver comes from a reliable source as well. All of this information also applies to history questions.

17.    You are growing fatigued of performing a maneuver on examination because you have never found a positive and are usually pressed for time. How should you next approach this maneuver?

A)    Use this test when you have a higher suspicion for a certain correlating condition.

B)    Omit this test from future examinations.

C)    Continue doing the test, but rely more heavily on laboratory work and diagnostics.

D)    Continue performing it on all future examinations.

Ans: A Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: This is an example of a specific test that lacks sensitivity. With this scenario, when you finally find a positive, you might be very certain that a given condition is present. We generally develop our examinations to fit our clinical experiences. Sensitive tests are performed routinely on the screening examination, while specific tests are usually saved for the detailed or “branched” examinations. Branched examinations are further maneuvers we can perform to investigate positive findings on our screening examinations. Save this type of maneuver to

confirm your hypothesis. All of this information also applies to history questions.

18.    You have recently returned from a medical missions trip to sub-Saharan Africa, where you learned a great deal about malaria. You decide to use some of the same questions and maneuvers in your “routine” when examining patients in the midwestern United States. You are disappointed to find that despite getting some positive answers and findings, on further workup, none of your patients has malaria except one, who recently emigrated from Ghana. How should you next approach these questions and maneuvers?

A)    Continue asking these questions in a more selective way.

B)    Stop asking these questions, because they are low yield.

C)    Question the validity of the questions.

D)    Ask these questions of all your patients.

Ans: A Chapter: 02

Page and Header: 38, The Challenges of Clinical Data

Feedback: The predictive value of a positive finding depends upon the prevalence of a given disease in a population. The prevalence of malaria in the Midwest is almost zero, except in people immigrating from areas of high prevalence. You will waste time and resources applying these questions and maneuvers to all patients. It would be wise to continue applying what you learned to those who are from areas of high prevalence of a given disease. Likewise, physicians from Ghana should not ask about signs or symptoms of multiple sclerosis, as it is found almost exclusively in northern latitudes. You will learn to tailor your examination to the population you are serving.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 3: Interviewing and the Health History

Multiple Choice

1.    You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses' station because a family member of one of your patients

wants to talk with you about that patient's care. You have clinic this afternoon and are double- booked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient?

A)    Irritability

B)    Impatience

C)    Boredom

D)    Calm

Ans: D Chapter: 03

Page and Header: 58, Getting Ready: The Approach to the Interview

Feedback: The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer.

2.    Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient–provider interview?

A)    Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story.

B)    Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport.

C)    Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan.

D)    Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport.

Ans: C Chapter: 03

Page and Header: 60, Learning About the Patient: The Sequence of the Interview Feedback: This is the most productive sequence for the interview. Greeting patients and

establishing rapport allows them to feel more comfortable before “inviting” them to relate their story. After hearing the patient's story, together you establish the agenda regarding the most important items to expand upon. At the end, together you negotiate the plan of diagnosis and treatment.