Assessment Q-Let Midterm EXAM UPDATED 2020 (CHAPTER 1- 11) (ALREADY GRADED A)

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Assessment Q-Let Midterm Ch1 1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of ... data would be: 2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: 3. The patients record, laboratory studies, objective data, and subjective data combine to form the: 4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? 8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? 10. Which critical thinking skill helps the nurse see relationships among the data? 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? 14. Which of these would be formulated by a nurse using diagnostic reasoning? 15. Barriers to incorporating EBP include: 16. What step of the nursing process includes data collection by health history, physical examination, and interview? 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? 19. The nurse recognizes that the concept of prevention in describing health is essential because: 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? 22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history? A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: In the health promotion model, the focus of the health professional includes: The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? Which statement best describes a proficient nurse? A proficient nurse is one who: The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. 1. a = First-level priority problem 2. b = Second-level priority problem 3. c = Third-level priority Ch 2 The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? When discussing the use of the term subculture, the nurse recognizes that it is best described as: When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: The nurse recognizes that an example of a person who is heritage consistent would be a: After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with: Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects health in an Asian with this belief? Illness is considered part of life’s rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory? An individual who takes the magic religious perspective of illness and disease is likely to believe that his or her illness was caused by: If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action? Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain? The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality: The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman’s sister until they can get a home of their own. When company arrives to visit with the woman’s sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing: After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is: The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient? During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: Ch. 3 The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? The nurse makes which adjustment in the physical environment to promote the success of an interview? In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-ta king? The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be:. When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesn’t understand how hard I’ve tried. I just don’t know the best way to do it. What should I do? The nurses most appropriate response in this case would be: As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, I’m so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You don’t smoke, drink, or take drugs, do you? This question is an example of: When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why haven’t you taken your insulin? Which statement is an appropriate evaluation of this question? The nurse is nearing the end of an interview. Which statement is appropriate at this time? During the interview portion of data collection, the nurse collects __________ data. During an interview, the nurse would expect that most of the interview will take place at what distance? A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: Ch. 4 The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care? A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response? A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the womans statement?. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information? The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: The review of systems provides the nurse with: Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram? A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating? The nurse is incorporating a persons spiritual values into the health history. Which of these questions illustrates the community portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? Ch 5 During an examination, the nurse can assess mental status by which activity? The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to: A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. During a mental status assessment, which question by the nurse would best assess a person's judgment? Which of these individuals would the nurse consider at highest risk for a suicide attempt? The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient's level of consciousness would be: A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem? A patient repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." The nurse will note on his chart that he is using or experiencing: During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's: A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?. Th nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. Ch. 6 A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as: The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries? During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which illicit substance was most commonly used? A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, How many drinks a day is safe for my baby? The nurses best response is: When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? During an assessment, the nurse asks a female patient, How many alcoholic drinks do you have a week? Which answer by the patient would indicate at-risk drinking? The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, Yes, Ive used marijuana at parties with my friends. What is the next question the nurse should ask? The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4 C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance? The person: A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? Select all that apply. A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop cold turkey. He asks the nurse, What symptoms can I expect if I do this? Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? Select all that apply. Ch. 7 As mandatory reporter of elder abuse, which of the following must be present before a nurse notifies the authorities? During a home visit, the nurse notes that an elderly woman is caring for her bedridden husband. The woman estates that this is her duty and that she does the best she can and her children come to help when they are in town. Her husband is unable to care for himself, and exhausted. The nurse notices the several of his prescription medication bottles are empty. This situation is best described by the term: The nurse is aware that intimate partner violence (IVP) screening should occur with which situation? Which statement is best for the nurse to use when preparing to administer the abuse assessment screen? Which term refers to a wound produced by the tearing and/or splitting of body tissue, usually from blunt impact over a bony surface? During an examination, the nurse notices a patterned injury of a patient’s back. Which of the following would cause of such an injury? When documenting intimate partner violence and elder abuse, the nurse should include: A female patient has denied any abuse when answering the Abuse Assessment Screen, but the nurse has noticed some other conditions that are associated with intimate partner violence. Example of such conditions include: The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide. Which of the following statements describes its use? When assessing bruising, which color indicates a new bruise that is less than 2 hours old? During a home visit, the nurse notices that an elderly woman has very little food in her cabinets or refrigerator and the most of her prescription bottles are empty. She says she has enough money, but her nephew has her checkbook and “he takes care of everything” She says, “Oh, may nephew will get around to getting groceries and my medicine when he can but he is very busy.” This is an example of: The nurse suspect abuse when a 10 year old child is taken to the urgent care center for a leg injury. The best way to document the history and physical finding is to: During an interview, a woman has answered “yes” to two of the Abuse Assessment Screen questions. What should the nurse say next? The nurse is assessing an elderly woman and suspects abuse. Which questions are appropriate for screening abuse? Ch. 8 When performing a physical assessment, the first technique the nurse will always use is: The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspections phase: The nurse is assessing a patient’s skin during an office visit. Which part of the hand and technique should be used to best assess the patient’s skin temperature? Which of there techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? The nurse is preparing to assess a patient’s abdomen by palpation. Hoe should the nurse proceed? The nurse would use bimanual palpation technique in which situation? The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the _____ of the underlying tissue. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse indicates that more review is needed? When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? The nurse hears bilateral loud, long and low tones when percussing over the lungs of a 4 year old child. The nurse should: A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient n oxygen, on which of these actions is the best for the nurse to take when assessing the patient? The nurse is teaching a class on basic assessment skills. Which one of these statements is true regarding the stethoscope and its use? The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is near sighted. The use of which of these techniques would indicate that the examination is being correctly performed? The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable? When performing a physical examination, safety must be considered to protect the examiner and the patient against the statements and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should taken when performing a physical examination? The nurse is examining the lower leg and notices a draining ulceration. Which of the these actions is most appropriate in this situation? During the examination, offering some brief teaching about the patient’s body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate? The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? When preparing to perform a physical examination on an infant, the nurse should: A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurse's technique is most accurate: With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on the penlight? The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? When examining a 16-year-old male teenager, the nurse should: Ch. 9 The nurse is performing a general survey. Which action is a component of the general survey? When measuring a patients weight, the nurse is aware of which of these guidelines? A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would: The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? The nurse should measure rectal temperatures in which of these patients? The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct? The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: When assessing an older adult, which vital sign changes occur with aging? The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? When measuring a patient’s body temperature, the nurse keeps in mind that body temperature is influenced by: When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature? A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. The nurse knows that: When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? To assess a rectal temperature accurately in an adult, the nurse would: Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: When assessing a patients pulse, the nurse should also notice which of these characteristics? When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurses next action would be to: When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature 36 C; pulse 48 beats per minute; respirations 14 breaths per minute; blood pressure 104/68 mm Hg. Which statement is true concerning these results? The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations? A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is: While measuring a patients blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: The nurse is preparing to measure the vital signs of a 6-month-old infant. The nurse will: What type of blood pressure measurement error is most likely to occur if the examiner does not check for the presence of an auscultatory gap? Which of the following specific measurements is the best index of a child's general health? Ch10 When evaluating a patient's pain, the nurse knows that an example of acute pain would be: Which statement indicates that the nurse understands the pain experienced by an older adult? A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain? A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the: The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the: A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? When assessing the quality of a patient's pain, the nurse should ask which question? When assessing a patient's pain, the nurse knows that an example of visceral pain would be: The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? When assessing the intensity of a patient's pain, which question by the nurse is appropriate? A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? The nurse knows that which statement is true regarding the pain experienced by infants? A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. Ch. 11 The nurse recognizes which of these persons is at greatest risk for undernutrition? When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that: The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find? For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity? A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information? The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? A patient tells the nurse that his food simply does not have any taste anymore. The nurse's best response would be: The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult? When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the woman's weight? How should the nurse perform a triceps skinfold assessment? In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk? A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find? The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate? Which of these conditions is due to an inadequate intake of both protein and calories? During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin? A 50-year-old patient has been brought to the emergency department after a housemate found that the patient could not get out of bed alone. He has lived in a group home for years but for several months has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia, which is a deficiency of:. An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient's gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition? The nurse is assessing a patient who is obese for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. [Show More]

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