NURS 310 GSS Exam 1 Review Questions & Answer Key with Rationales,100% CORRECT

NURS 310 GSS Exam 1 Review Questions & Answer Key with Rationales 1. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: A. Patient’s history of allergies B. Patient’s use of medications at home C. Last menstrual period 1 month ago D. 2x5 cm scar on the right lower forearm Explanation: A scar is observed directly by the nurse. All of the other data points are (most likely) told to the nurse by the patient. 2. A patient's weekly blood pressure for two months ranged between 124/84mmHg and 136/88mmHg, with an average of 126/86mmHg. The nurse knows that this blood pressure falls within which category? A. Normal B. Stage 1 HTN C. Prehypertension D. Stage 2 HTN Explanation: Prehypertension BP readings are systolic of 120 to 139mmHg or diastolic of 50 to 89mmHg. 3. 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. Collect history information first, then perform the physical examination and institute life-saving measures B. Simultaneously ask history questions while performing the examination and initiating life-saving measures C. Cellect all information on the history form, including social support patterns, strengths, and coping patterns D. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit Explanation: The emergency database calls for a rapid collection of the database, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation. Even in emergent situations, some information is essential to get from the patient if at all possible, in order to administer safe care (identity, allergies, medications, etc.) 4. The nurse is performing a general survey. Which action is a component of the general survey? A. Observing the patient’s body stature and nutritional status B. Observing specific body systems while performing the physical assessment C. Interpreting the subjective information the patient has reported D. Measuring the patients temp., pulse, RR, & BP Explanation: The general survey is a study of the whole person that includes observing the patients physical appearance, body structure, mobility, and behavior. 5. You’re examining a 54yo male patient in the emergency department. Patient was admitted after a short attack of severe chest pain (8/10 on pain scale) and reveals that it began while he was mowing the lawn. Patient is 5’9 and weighs 218lbs. Patient states that he’s had chest pain before but never this bad, he always assumed it was just heartburn. Patient has a BP of 144/86, HR of 106, RR 28, temperature 99.1. What information is subjective? What happened. Severity of the pain. Pretty much any and all PQRST or OLDCART. 6. You’re examining a 54yo male patient in the emergency department. Patient was admitted with severe chest pain (8/10 on pain scale) and reveals that it began while he was mowing the lawn. Patient is 5’9 and weighs 218lbs. Patient states that he’s had chest pain before but never this bad, he always assumed it was just heartburn. Patient has a BP of 144/86, HR of 106, RR 28, temperature 99.1. What information is objective? All vital signs, BMI 7. Same patient is stable, pain has subsided, and medications and blood draws have been administered in case of heart attack. What are some questions that you could ask as part of your patient interview? (It’s ok that you haven’t covered cardiac yet. This is practice for thinking critically) Focused: Medical history, Family history, Lifestyle 8. When assessing an older adult, which vital sign changes occur due to aging? A. Increase in body temperature B. Widened pulse pressure C. Decrease in diastolic BP D. Increase in pulse rate Explanation: With aging, keep in mind that the systolic BP increases, due to stiffening of the arterial walls, leading to widened pulse pressure. The pulse rate and temperature do not increase. Both systolic and diastolic pressure increases. Pulse pressure equals SBP - DBP. 9. Which situation is most appropriate during which the nurse performs a focused or problem- centered history? A. Patient is admitted to a long-term care facility B. Patient has a sudden and severe shortness of breath C. Patient is admitted to the hospital for surgery the following day D. Patient in an outpatient clinic has cold and influenza-like symptoms Explanation: In a focused or problem-centered database, the nurse collects a “mini” database, which is smaller in scope than the completed database. This mini data base primarily concerns one problem, one cue complex, or one body system. It is also typically a short term or limited problem that is being addressed. Admission into a long-term care facility would warrant a complete health assessment. Sudden and severe shortness of breath requires the urgent, rapid collection of information (potentially while administering life-saving care), therefore would be an emergency database. A patient admitted to the hospital for surgery the following day would receive a followup assessment. 10. The nurse should measure rectal temperature in which of these patients? A. Patient with a nasogastric tube (NG tube) B. Comatose adult C. 18-year-old D. Older adult Explanation: Rectal temperatures should be taken when the other routes are impractical, such as for a confused or comatose person, for those in shock, or those who cannot close their mouth due to breathing or oxygen tubes, a wired mandible, or other facial dysfunctions. 11. When taking a blood pressure reading, the systolic blood pressure is which of the following? A. The point when the first sound is heard B. The point where the pulse is no longer felt C. The point where the last sound is heard D. The point 20-30 mm Hg above where the pulse was last felt 12. A patient is admitted with confusion among other signs and symptoms. What questions are appropriate to ask to determine a patient's orientation? (select all that apply) A. What year is it? B. What did you have for breakfast? C. Do you know where you are? D. Do you know why you’re here? E. What is your name? F. All of the above Explanation: You want to assess whether the patient is alert and oriented to person (who they are), place (where they are), time (day/month/year) and situation (why they're there). You'll see this documented as Alert & Oriented x4 (A&Ox4). You may see this as just “oriented x3”. 13. Which technique is correct when assessing the radial pulse of a patient? A. 15 seconds and then multiplied by 4, if the rhythm is regular. B. 1 minute, if the rhythm is irregular. C. 10 second and then multiplied by 6, if the patient has no history of cardiac abnormalities D. 2 full minutes to detect any variation in amplitude Explanation: The 30-second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are normal. If the rhythm is irregular, then the pulse is counted for 1 full minute. 14. The nurse is assessing the vital signs of a 25-year-old male marathon runner and documents the following vital signs: temperature 36C/96.8F; pulse 48 beats/min; respirations 14 breaths/min; BP 104/68 mmHg. Which statement is true? A. The patient’s pulse rate is not normal. His physician should be notified. B. These are normal vital signs for a healthy, athletic adult. C. On the basis of these readings, the patient should return to the clinic in 1 week. D. The patient is experiencing tachycardia. Explanation: In the adult, a HR less than 50 beats/min is called bradycardia, which normally occurs in the well-trained athlete whose heart muscle develops along with the skeletal muscles. 15. Which of the following are open-ended questions? (SATA) A. What medications are you taking? B. Are you experiencing any pain? C. What are your expectations going forward with treatment? D. Has your headache gotten any better since you took tylenol? E. Tell me about your living situation at home. 16. Explain or give an example of the following verbal responses: Facilitation Silence Reflection Empathy Clarification Confrontation Interpretation Explanation Summary 17. The nurse is assessing the vital signs of a 5-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child’s respirations? A. Child respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern. B. Patient’s respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute. C. Respirations should be counter for 1 full minute, noticing rate and rhythm. D. Child’s respirations and pulse should be simultaneously checked for 30 seconds. Explanation: Respirations are counted for 1 full minute, if abnormality is suspected. The other responses are not correct actions. 18. A patient confides in you, her nurse, that she has been extremely stressed due to marital problems. What would be an appropriate response? A. I know how you feel. My boyfriend and I have been having trouble lately too. I made one snide remark to his parents at Christmas and now he barely talks to me. B. I’m sorry to hear that. Would you like me to bring you some water? C. I’m sure it will work out, just give it some time. D. Would you be interested in talking to one of our in-hospital family counselors? E. If I were in your position I would say bye boi. There’s more fish in the sea, you know. 19. A patient’s BP is 170/80 mmHg. He asks the nurse, What do the numbers mean? The nurses best reply is? A. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts. B. The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic number. C. The numbers are within normal range and are nothing to worry about. D. The bottom number is the diastolic pressure and reflects the stroke volume of the heart. Explanation: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should and the patient’s question and use terms he can understand. NO JARGON! 20. When it comes to assessing the client’s physical appearance, which of the following would a nurse make note of? A. Gender, age, ethnicity, dress, speech, level of consciousness B. Religion, age, ethnicity, dress, speech, level of consciousness C. Age, gender, ethnicity, dress, diet, speech, level of consciousness D. Gender, age, ethnicity, marital status, dress, speech, level of consciousness 21. While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as , help determine blood pressure. A. Vascular Output B. Pulse Rate C. Peripheral Vascular Resistance D. Pulse Pressure Explanation: The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. 22. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: A. Avoid missing a falsely elevated blood pressure. B. More readily identify phase IV of the Korotkoff sounds. C. More clearly hear the Korotkoff sounds. D. Detect the presence of an auscultatory gap. Explanation: Inflation of the cuff 20 to 30mmHg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation. 23. A woman brings her infant (11mo) into the clinic and tells you that she thinks he has an ear infection. She says that he started holding onto his ear and crying that morning, had no appetite, and woke more than usual during the night. Upon examination of the child’s ear, you notice that his tympanic membrane is red and bulging. The child has a fever of 101, RR of 46, HR 188. What subjective data do you know? What does the objective data suggest? What questions might you ask the mother as part of the interview? Normal VS for an infant (11mo): RR, 24-38; HR 80-150 w/rest, 220 w/fever. 24. A 80-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? A. Blood pressure and pulse are assessed at the beginning and at the end of the examination. B. Blood pressure and pulse should be recorded in the supine, sitting, and standing position. C. Blood pressure is taken on the right arm and then 10 minutes later on the left arm. D. The patient should be directed to walk around the room and his blood pressure assessed after this activity. Explanation: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded i the supine, sitting, and standing positions. 25. The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: A. Be the same, regardless of cuff size. B. Vary as a result of the technique of the person performing the assessment. C. Yield a falsely low blood pressure. D. Yield a falsely high blood pressure Explanation: Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery. 26. A mother and her 14yo daughter enter the examination room for the daughters annual physical. You ensure the family has privacy by closing the door and letting colleagues know that you will be busy. You discuss the daughters current health status, medical/surgical history, and medication use. Next you plan to ask some questions about lifestyle. As the nurse, what should you be cognitive of? A. Teenagers will lie about this stuff B. The mother is likely to provide more thorough answers C. Patient’s are more comfortable if the nurse shares personal information first D. Lifestyle questions really aren’t necessary for this age E. Nurse must treat material as matter of fact, with no judgement F. E, but also mom is sus, attempt to interview daughter privately 27. A 80-year-old man has a blood pressure of 150/80mmHg in a lying position, 130/80mmHg in a sitting position, and 100/60mmHg in a standing position. How should the nurse evaluate these findings? A. The blood pressure in the lying position is within normal limits. B. These readings are a normal response and attributable to changes in the patient’s positions. C. The change in blood pressure is considered within normal limits for the patients age. D. The change in blood pressure is called orthostatic hypotension. Explanation: Orthostatic hypotension is a drop in systolic pressure of more than 20mmHg, which occurs with a quick change to ao standing position. Aging people have the greatest risk of this problem. 28. 58yo reports frequent bouts of dizziness. As the nurse you suspect that she may be experiencing orthostatic hypotension. Which explanation is most appropriate to provide to the patient? A. You have low blood pressure, so when you stand up quickly you will feel dizzy and might faint B. This is a problem generally experienced by patients with heart failure C. When you abruptly change from prone to a standing position, your experience peripheral vasodilation causing your systolic blood pressure drops more than 20 mmHg or your diastolic blood pressure drops more than 10 mmHg, which in turns limits oxygen perfusion to your brain, resulting in syncope D. Quick changes in position cause temporary hypotension that may result in dizziness or fainting. If this occurs, sit back down until the symptoms go away, and then slowly try to stand again. 29. The nurse is counting a patient’s respirations. Which technique is correct? A. Watching the chest rise and fall B. Placing a hand across the patient’s chest C. Using a stethoscope to listen to the breath sounds D. Watching the abdomen for movement Explanation: Watching the chest rise and fall is the correct technique. The abdomen is the technique for infant respirations. The other responses do not reflect correct techniques. 30. While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? (SATA) A. The arm is held above level of the heart. B. The cuff is loosely wrapped around the arm. C. The nurse does not inflate the cuff high enough. D. The person supports his or her own arm during the blood pressure reading. E. The blood pressure cuff is too narrow for the extremity. F. The person is sitting with his or her legs crossed. Explanation: Several factors can result in blood pressure readings that are too high or too low. Having the patient’s arm held above the level of the heart is one part of the correct technique.