NR 509 WEEK 1 QUIZ / NR509 WEEK 1 QUIZ: LATEST,CHAMBERLAIN COLLEGE OF NURSING

NR 509 WEEK 1 QUIZ / NR509 WEEK 1 QUIZ: LATEST,CHAMBERLAIN COLLEGE OF NURSING Question 1. Question : The nurse is classifying nursing diagnoses. Which of these would be considered a risk diagnosis? Student Answer: Identifying existing levels of wellness Evaluating previous problems and goals Identifying potential problems the individual may develop Focusing on strengths and reflecting an individual’s transition to higher levels of wellness Question 2. Question : Barriers to incorporating evidence-based practice (EBP) include Student Answer: nurses’ lack of research skills in evaluating quality of research studies. lack of significant research studies. insufficient clinical skills of nurses. inadequate physical assessment skills. Question 3. Question : When reviewing concepts of health, the nurse recalls that components of holistic health include which of these? Student Answer: Disease originates from the external environment. The individual human is a closed system. Nurses are responsible for a patient’s health state. Holistic health views the mind, body, and spirit as interdependent. Question 4. Question : The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? Student Answer: Establish priorities. Identify expected outcomes. Evaluate the individual’s condition and compare actual outcomes with expected outcomes. Interpret data and then identify clusters of cues and make inferences. Question 5. Question : 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. Student Answer: summary closing body opening or introduction Question 6. Question : In using verbal responses to assist the patient’s narrative, some responses focus on the patient’s frame of reference and some focus on the healthcare provider’s perspective. An example of a verbal response that focuses on the healthcare provider’s perspective would be Student Answer: empathy. reflection. facilitation. confrontation. Question 7. Question : 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? Student Answer: “Mr. Y., at your age, surely you have been hospitalized before!” “Mr. Y., I just need permission to get your medical records from County Medical.” “Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?” “Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?” Question 8. Question : 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 nurse’s best reaction would be Student Answer: “Stop that immediately!” “Oh, you are too funny. Let’s keep going with the interview.” “Do you really think I would be interested?” “It makes me uncomfortable when you talk that way. Please stop.” Question 9. Question : 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? Student Answer: P-6, B-4, (S)Ab-2 Grav 6, Term 4, (S)Ab 2, Living 4 Patient has had four living babies. Patient has been pregnant six times. Question 10. Question : A 90-year-old patient tells the nurse that he can’t 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 Student Answer: “Can you tell me what they look like?” “Don’t worry about it. You are only taking two medications.” “How long have you been taking each of the pills?” “Would you have your family bring in your medications?” Question 11. Question : The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion of the FICA questions? Student Answer: “Do you believe in God?” “Are you a part of any religious or spiritual congregation?” “Do you consider yourself to be a religious or spiritual person?” “How does your religious faith influence the way you think about your health?” Question 12 Question : 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? Student Answer: Chest pain Clammy skin Serum potassium level 4.2 mEq/L A temperature of 100? F Question 13. Question : The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? Student Answer: “Maybe she is just teething.” “I will check her ear for an ear infection.” “Are you sure she is really having pain?” “Please describe what she is doing to indicate she is having pain.” Question 14. Question : 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? Student Answer: Auscultate the lungs and heart while the infant is still sleeping. Examine the infant’s hips because this procedure is uncomfortable. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems. Question 15. Question : When preparing to perform a physical examination on an infant, the nurse should Student Answer: have the parent remove all clothing except the diaper on a boy. instruct the parent to feed the infant immediately before the examination. encourage the infant to suck on a pacifier during the abdominal examination. ask the parent to briefly leave the room when assessing the infant’s vital signs. Question 16. Question : The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope Student Answer: is often used to direct light onto the sinuses. uses a short, broad speculum to help visualize the ear. is used to examine the structures of the internal ear. directs light into the ear canal and onto the tympanic membrane. Question 17. Question : Which of these statements is true regarding the use of standard precautions in the healthcare setting? Student Answer: Standard precautions apply to all body fluids, including sweat. Use alcohol-based hand rub if hands are visibly dirty. Standard precautions are intended for use with all patients regardless of their risk or presumed infection status. Standard precautions are to be used only when there is nonintact skin, excretions containing visible blood, or expected contact with mucous membranes. Question 18. Question : Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? Student Answer: Palpation Inspection Percussion Auscultation Question 19. Question : The nurse is examining a patient who is complaining of “feeling cold.” Which is a mechanism of heat loss in the body? Student Answer: Exercise Radiation Metabolism Food digestion Question 20. Question : The nurse is taking an initial blood pressure on a 72-year-old patient with documented hypertension. How should the nurse proceed? Student Answer: Place the cuff on the patient’s arm and inflate it 30 mm Hg above the patient’s pulse rate. Inflate the cuff to 200 mm Hg in an attempt to obtain the most accurate systolic reading. Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears. Look at the patient’s past blood pressure readings and inflate the cuff 30 mm Hg above the highest systolic reading recorded. Question 21. Question : When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure? Student Answer: 200/92 200/100 100/200/92 200/100/92 Question 22. Question : The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? Student Answer: Measure respirations and then pulse and temperature. Measure vital signs more frequently than in an adult. Explain procedures and encourage the infant to handle the equipment. Allow the infant to become familiar with the nurse by performing the physical examination first and then measuring the vital signs. Question 23. Question : When assessing an older adult, the nurse keeps in mind that which vital sign changes occur with aging? Student Answer: Increase in pulse rate Widened pulse pressure Increase in body temperature Decrease in diastolic blood pressure Question 24. Question : The nurse knows that which statement is true regarding the pain experienced by infants? Student Answer: Pain in infants can only be assessed by physiologic changes, such as increased heart rate. The Faces Pain Scale—revised (FPS-R) can be used to assess pain in infants. A procedure that induces pain in adults will also induce pain in the infant. Infants feel pain less than adults do. Question 25. Question : When evaluating a patient’s pain, the nurse knows that an example of acute pain would be Student Answer: arthritic pain. fibromyalgia. kidney stones. low back pain.