NURSING NUR 2214 Chapter 11&12 Practice Questions and Answers,100% CORRECT

NURSING NUR 2214 Chapter 11&12 Practice Questions and Answers CHAPTER 1 • 1. A patient is admitted to the medical-surgical unit with a diagnosis of hypertension. The nurse is using the nursing process to develop the plan of care. Which steps should the nurse incorporate? Assessment, treatment, planning, evaluation, discharge, follow-up Admission, discharge, and follow-up planning are included in the assessment database but are not considered part of the nursing process. Admission, assessment, diagnosis, treatment, discharge planning Admission and discharge are part of the nursing database. Admission, diagnosis, treatment, evaluation, discharge planning Discharge planning is a part of the nursing database. Assessment, diagnosis, outcome identification, planning, implementation, evaluation The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nurse must analyze and interpret these data before initiating a plan of care. • 2. The nurse is incorporating the principles of the quality and safety competencies from the Institute of Medicine (IOM) recommendations into the health assessment of a patient in the long-term care setting. What principles should the nurse consider? Select all that apply: Use evidence to support interventions. Evaluate the plan of care. Use a step-by-step approach to problem solving. Use technologies and informatics in delivering care. Place the patient at the center of care. Include other disciplines in the plan of care. The Institute of Medicine identified five core competencies as essential for health care professionals to demonstrate how to respond effectively to patient care needs: provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics. • 3. The student nurse is preparing to assess a patient in the hospital clinical setting. Which components best describe the concept of health assessment? Select all that apply: Collection of objective data Collection of subjective data Collection of data and identification of nursing diagnosis Planning and evaluation of data Analysis of data Physical exam Documentation of data Components of health assessment include conducting a health history (the collection of subjective data), performing a physical examination (the collection of objective data), and documenting the findings. • 4. The nurse is documenting the findings from the health assessment. Which example of data documentation reflects the opinion of the nurse? The patient is uncooperative and unfriendly. Correct Nurses must record data accurately, concisely, and without bias or opinion. In this example, the nurse is offering an opinion, which may contain bias. The patient avoids eye contact. Avoidance of eye contact is objective data. The patient states, “I do not want to get out of bed.” A direct quote helps to communicate the patient’s feelings. The patient states, “I am very angry.” A direct quote helps to communicate the patient’s feelings. • 5. The nurse is assessing a patient for the first time in the outpatient diabetic clinic. A type of health assessment would be most appropriate for this visit? Focused assessment Focused assessment involves a history and examination that are limited to a specific problem or complaint. Episodic follow-up assessment A follow-up assessment usually is performed when a patient is following up with a health care provider for a previously identified problem. Shift assessment The purpose of the shift assessment is to identify changes in the patient’s condition from baseline; thus the focus of the assessment is based largely on the condition or problem the patient is experiencing. Comprehensive health assessment The type of health assessment performed by the nurse is also driven by patient need. A comprehensive health assessment involves a detailed history and physical examination performed at the onset of care in a primary care setting or upon admission to a hospital or long-term care facility. • 6. A patient complains of a cough for 4 days unrelieved with position changes. The nurse interprets this as a symptom and documents the finding under on the patient’s chart. The nursing care plan The nursing care plan would include intervention for this symptom. Assessment A nursing assessment and diagnosis are based on subjective and objective data. History A symptom is something described by the patient and considered subjective; therefore it would be documented under “History.” Vital signs Vital signs are objective data. • 7. The nurse is administering an influenza (flu) shot to a patient in a retail health setting. Of which level of prevention is this an example? Primary Vaccinations protect from disease and are considered primary prevention. Secondary Secondary prevention involves screening patients in an effort to detect disease early and prevent complications from the disease. Post secondary Post secondary is another term for college education and is not used for levels of prevention. Tertiary Tertiary prevention involves patients who have been diagnosed with a disease and teaching them how to best manage the disease. • 8. A patient tells the nurse that he has had a headache and nausea for 3 days. Which type of assessment should the nurse perform? Focused assessment The type of health assessment performed by the nurse is also driven by patient need. A focused assessment involves a history and examination that are limited to a specific problem or complaint. Episodic follow-up assessment A follow-up assessment usually is performed when a patient is following up with a health care provider for a previously identified problem. Shift assessment The purpose of the shift assessment is to identify changes in patient’s condition from baseline; thus the focus of the assessment is based largely on the condition or problem the patient is experiencing. Comprehensive health assessment A comprehensive health assessment involves a detailed history and physical examination performed at the onset of care in a primary care setting or upon admission to a hospital or long-term care facility. • 9. The nurse is conducting a data analysis on objective information obtained during the health history. What should be included? Select all that apply Vital signs Pain assessment Review of symptoms Surgical history Social history Heart murmur Pain assessment, review of symptoms, surgical history, and social history are considered subjective data. • 10. The refers to the circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to physical, psychological, or socioeconomic circumstances involving patients, or the expertise of the nurse. Body systems assessment A body systems format is used to perform a physical assessment. Nursing process The nursing process refers to a systematic approach to problem-solving and care planning. Health promotion interventions Health promotion activities are included in the nursing care plan. Context of care The context of care refers the circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to physical, psychological, or socioeconomic circumstances involving patients, or the expertise of the nurse. For this reason, different types of assessments are performed. Examples of different types of assessment include a comprehensive health assessment, a problem- based or focused health assessment, an episodic assessment, and a screening assessment. CHAPTER 4 • 1. The nurse is taking a patient’s oral temperature. How should the nurse perform the procedure? The thermometer should be placed: Under the tongue next to the frenulum of the lower lip The thermometer should be placed farther into the mouth than inside the lower lip. Under the tongue in the posterior sublingual pocket Correct Placing the thermometer under the tongue in the posterior sublingual pocket provides the most accurate temperature. Between the tongue and the hard palate This describes a position on top of the tongue and against the roof of the mouth. Along the outer aspect of the lower molars and against the cheek The thermometer should be placed under the tongue, not against the cheek. Incorrect • 2. The nurse is counting an infant’s respirations. Which technique is correct? Watch the chest rise and fall. The nurse would assess an adult by watching the chest rise and fall. Watch the abdomen for movement. Correct Watch the infant’s abdomen for movement because the infant’s respirations are normally more diaphragmatic than thoracic. Place a hand across the infant’s chest. This technique would be useful for assessing tactile fremitus. Use a stethoscope to listen to the breath sounds. On an infant, the heart, bowel, and lung sounds make it difficult to assess respiration with a stethoscope. • 3. The nurse is auscultating the lungs to listen for breath sounds. What sounds will indicate that the nurse is auscultating correctly? The nurse will hear the diffusion of air and carbon dioxide. Diffusion and carbon dioxide are measured through laboratory studies. The nurse will hear the air move in and out of the lungs. Correct If the stethoscope is placed over the lung fields, the nurse should hear air moving in and out of the lungs. The nurse will hear a “lub/dub” sound. The stethoscope should be moved; this is the sound of the patient’s heart. The nurse will hear gurgling noises. The stethoscope should be moved; these are most likely bowel sounds. • 4. The nurse knows that the blood vessels should be used to assess an adult’s blood pressure. Carotid artery The carotid artery is in the neck. Brachial vein Veins are not used to assess blood pressure. Brachial artery Correct The brachial artery is found near the antecubital space. Radial artery The radial artery is located in the wrist and is not routinely used for blood pressure assessment. • 5. The nurse is obtaining a pulse oximeter reading on an adult patient. Where is the probe of a pulse oximeter placed? In the mouth or under the arm These locations are used to assess temperature, not pulse oximeter. On the ear The ear may be used in infants and young children. The pulse oximeter is taped in place. On the tip of a finger or toe or on an ear lobe Correct It is important to know how to attach the probe. In the rectum The rectum can be used to determine temperature. • 6. The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient’s: Defer temperature for this age group Deferring the temperature may eliminate an important finding. Also, children have thermoregulation issues that would need assessment. Oral An oral temperature may be difficult to obtain secondary to activity level of toddler. Rectal It may be difficult for the nurse to obtain a rectal temperature on a toddler. Tympanic Correct Tympanic is preferred secondary to activity level of toddler and efficiency of method. • 7. An adult patient is being assessed in the outpatient clinic secondary to a recent weight loss. Why is the weight of an adult patient measured routinely during a physical assessment? It allows assessment of body fat content. Body fat can be estimated but not measured with body weight. A change in body weight can be indicative of health problems. Correct This is especially true with a sudden, excessive weight gain or loss. Fat deposits in specific locations can be identified. Measurement of body weight does not identify specific body fat deposits. It identifies patients who exercise and those who do not exercise. The amount or degree of exercise is not determined by body weight alone. • 8. The nurse is obtaining a patient’s blood pressure and suspects that the reading is a false high reading. What leads the nurse to confirm this suspicion? Using a cuff that is too narrow Correct A narrow cuff can result in a false-high reading. Having the examiner’s eyes looking down at the meniscus Having the examiner’s eyes looking down at the meniscus can result in a false-low reading. Deflating the cuff too rapidly Deflating the cuff too rapidly can result in a false-low reading. Positioning patient’s arm below the level of the heart Positioning the patient’s arm below the level of the heart can result in a false-low reading. • 9. The nurse is checking a patient’s heart rate. An appropriate technique for an adult patient is to: Use the pulse oximeter device to obtain heart rate. The pulse oximeter does give a heart rate reading; however, this may not reveal the quality of the pulse or irregularities in the heart rhythm. Use the automatic blood pressure cuff to obtain heart rate. The automatic blood pressure cuff does give a heart rate; however, this may not reveal the quality of the pulse or irregularities in the heart rhythm. Palpate the carotid artery for 1 full minute. The carotid artery generally is used when cardiopulmonary necessitation is warranted. A 10-second pulse is obtained. Palpate the radial artery for 15 seconds and multiply by 4 to obtain heart rate. Correct For adults, the radial artery is used generally for heart rate. • 10. The student nurse is learning how to obtain blood pressures and is studying what factors can affect blood pressure. What should the student nurse include as factors that affect blood pressure? Select all that apply: What the person ate Smoking Mobility Race Gender Weight Pain Gender: After puberty, females usually have a lower blood pressure than males; however, after menopause, women’s blood pressure may be higher than men’s. Race: The incidence of hypertension is twice as high in African Americans as in whites. Pain: Experiencing acute pain can increase blood pressure. Personal habits: Ingesting caffeine or smoking a cigarette within 30 minutes before measurement may increase blood pressure. Weight: Obese patients tend to have higher blood pressures than nonobese patients. Feedback: Eating and mobility do not have an effect on blood pressure. CHAPTER 5 • 1. An elderly African-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse should: Perform a physical examination Performing the physical assessment is a nursing task, not a means of showing sensitivity. Recognize and accept different beliefs about health Correct The nurse should recognize the difference in beliefs. Although the nurse does not have to agree with another’s beliefs, he or she must be accepting of those important to the patient. Identify high-risk patients for various diseases Identifying high-risk patients is part of health education, but it does not necessarily address cultural sensitivity. Apply statistical trends of various ethnic and cultural groups Applying statistical trends of various ethnic and cultural groups describes the epidemiology of illness. • 2. The nurse states, “All homosexuals have HIV infection.” This statement is an example of: Sexism Sexism is favoring one gender over the other. Prejudice Prejudice is favoring one nationality or race over the other. Stereotyping Correct Although some homosexuals have HIV infection, not all do. This is a stereotypical statement. Racism Race is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. Racism is prejudice against someone based on any of these characteristics. • 3. Which is a common mistake made by health care professionals when collecting data about ethnic and cultural considerations of a patient? Acknowledging the practice of folk or herbal remedies All health care individuals are encouraged to acknowledge alternative health practices of individuals from various cultures. Adapting health care concepts to meet the needs of individuals of other cultures The nurse is encouraged to adapt nursing care as much as possible to meet the ethnic or cultural needs of others. Assuming data about the patient based on skin color or ethnic group This is very easy to do but also can impair therapeutic relationships between the patient and nurse. It also interferes with providing care based on the patient’s needs. Overestimating the ability of individuals from diverse cultures to understand health care concepts Health care professionals are more likely to underestimate (not overestimate) a person from a culture other than their own. • 4. The nurse is performing a cultural assessment for an immigrant from Mexico. The patient is having difficulty adapting to the American health system. What is the most likely explanation for this problem? Culture shock Correct Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individual’s perceptions and expectations. Cultural taboos Cultural taboos are practices that are discouraged by the culture. Cultural unfamiliarity Cultural unfamiliarity is not a relative term for cultural assessment. Culture disorientation Cultural disorientation is not a relative term for cultural assessment. • 5. The nurse is reviewing concepts related to one’s heritage and beliefs. The belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: Culture Culture is the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Religion Correct Religion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Ethnicity Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, or race. Spirituality Spirituality is born out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. • 6. What standards or guidelines exist to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the United States of America? Each ethnic group has its own written standards for competent cultural care. This statement is incorrect. There are no standards or guidelines for giving competent cultural care. There are guidelines and standards. The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. Correct There are 14 standards that provide for culturally and linguistically appropriate services (CLAS). The American Society of Cultural Competence has guidelines containing the health beliefs and practices of major cultural groups. This is not a legitimate group. • 7. Examples of providing culturally competent care are: Select all that apply: Understands people from cultures other than his or her own Speaks at least one foreign language Seeks knowledge of the health beliefs and practice of all the cultures Has visited a foreign country Incorporates foods from home into the diet Allows for complementary interventions for pain relief Correct Feedback: Gaining an understanding of each patient’s culture is the basis for competent care, allowing for complementary modalities. Seeking knowledge and incorporating special food are examples of cultural competent care Incorrect Feedback: Speaking another language and visiting a foreign country are not prerequisites to providing cultural care. • 8. refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status. Discrimination Discrimination is excluding a person based on gender, age, culture, race, religion, or sexual orientation. Spirituality A review of spirituality definitions in health care literature provided several themes: relationship to God, a spiritual being, a higher being, or reality greater than the self; existential, not of the material world; meaning and purpose in life; and life force of the person or integrating aspect of the person. Religion may or may not be part of one’s spirituality. Culture sensitivity Cultural sensitivity is being aware of and sensitive to another’s culture. Diversity Correct Diversity refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status. Incorrect • 9. The nurse is assessing a patient•s spiritual beliefs and practices. Which questions should be considered part of the assessment? Select all that apply: What type of spiritual/religious support do you desire? What is the name of your clergy, ministers, chaplains, pastor, rabbi? What does pain mean to you? What does dying mean to you? What are your educational goals? Do you use prayer in your life? Correct Feedback: These are all questions related to spiritual assessment. Incorrect Feedback: Pain is part of physical and cultural assessment. Educational goals are not part of a nursing assessment. • 10. is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. Culture Culture includes all socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, life ways, and characteristics of a population that influence perception, behavior, and evaluation of the world. Religion Religion refers to an organized system of beliefs, rituals, and practices with which an individual participates, whereas spirituality is a broader term. Spirituality A review of spirituality definitions in health care literature provides several themes: relationship to God, a spiritual being, a higher being, or reality greater than the self; existential, not of the material world; meaning and purpose in life; and life force of the person or integrating aspect of the person. Religion may or may not be part of one’s spirituality. Race Correct Race is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. CHAPTER 6 • 1. The nurse is compelled to address and manage a patients pain level by which ethical principles? Select all that apply: CorrectBeneficence Liberty Autonomy Nonmaleficence Justice Correct Feedback: The ethical principles of beneficence (the duty to benefit another) and nonmaleficence (the duty to do no harm) compel health care professionals to provide pain management and comfort. Incorrect Feedback: Liberty and justice are ethical principles that deal with fairness. Autonomy deals with the patient’s right to make decisions independently. • 2. The nurse is assessing the degree of pain or discomfort a patient is feeling. The nurse knows that this will be dependent primarily on the: Ability to explain the pain or discomfort Pain may be experienced whether or not the stimulus can be explained. Perception of the pain or discomfort Correct Individuals may perceive a stimulus differently, making the pain experience very individualized. Age of the individual Although age may contribute to various causes of pain, age itself is not an indicator of the pain experience. Type of painful stimulus Individuals may perceive the same stimulus differently. • 3. The nurse is attending an in-service on pain management for postoperative patients. Which statement regarding pain is true? Select all that apply: An individual•s pain response is predictable based on his or her culture or ethnicity. Individuals from all cultures respond to pain similarly. CorrectThe pain response may be influenced by one’s culture. CorrectIndividuals may express pain differently. CorrectPain management may vary depending on the source of pain. Correct Feedback: Culture influences how an individual responds to pain. Pain tolerance is highly variable. Patients may need narcotics for postoperative pain, whereas muscle strains may respond well to anti-inflammatory medications. Incorrect Feedback: Pain is not predictable regardless of culture or ethnicity and cannot be stereotyped by culture. • 4. Which findings by the nurse would produce the most accurate assessment of the severity level of a patient’s pain? The nurse’s experience Nurses may have experience regarding what types of situations tend to cause more pain than others, but this is not a valid method for assessing pain severity. The cause of the pain Pain is an individual experience; thus the same stimulus may cause various responses from various individuals. The patient’s subjective data Correct The most accurate and reliable evidence of pain is the patient’s report. The patient’s objective findings Objective findings may contribute to pain assessment, but they do not describe the severity of pain the patient experiences. • 5. The nurse is assessing a patient who has pain with a sudden onset and a limited duration and that subsides as healing occurs. Which type of pain would this be considered? Acute pain Correct By definition, acute pain is pain that lasts less than 6 months. Chronic pain Chronic pain typically lasts longer than 6 months. Cancer pain Cancer pain changes over time as the disease progresses. Nonmalignant pain Nonmalignant pain may slowly increase and usually occurs over a long period of time. • 6. When assessing the quality of a patient’s pain, the nurse should ask which question? “When did the pain start?” Assessing when the pain started may determine the type of pain but not the quality of pain. “Is the pain a stabbing pain?” This question deals with type of pain. “Is it a sharp pain or dull pain?” The nurse would be influencing the patient’s responses by suggesting the type of pain. “What does your pain feel like?” Correct To assess the quality of a person’s pain, have the patient describe the pain in his or her own words. • 7. The nurse is reviewing the pathophysiology of pain. Where does the perception of pain actually occur? The dorsal horn of the spinal cord The dorsal horn of the spinal cord is the location of the “gate” of pain transmission. The parietal lobe of the cerebral cortex Correct Pain is not actually perceived until the parietal lobe is stimulated. The afferent (sensory) nerves Afferent nerves are involved in the transmission of the pain impulse. The visceral and somatic free nerve endings (nociceptors) Nociceptors are involved in the transduction of the pain process. • 8. pain is associated with feeling pain when a limb has been amputated. Phantom pain Correct This occurs most often in individuals who experienced pain in the appendage or limb before the amputation. Psychotic pain This is not a psychotic experience; it is fairly common among amputees. Chronic pain This type of pain could become chronic, but chronic pain is not limited to amputations. Invisible pain Invisible is not a term used to describe pain. • 9. The nurse is performing a pain assessment of a 4-year-old toddler. Which pain assessment scale would be best for this patient? Visual Analog Scale This scale is ideal for older adults secondary to hearing or visual deficits but not for young children. Numeric Pain Intensity Scale This scale ranges from 0 to 10; toddlers may not be able to articulate numbers. Wong/Baker Faces Rating Scale Correct This scale is works well for children over 3 years of age because it has pictures. Pain Intensity Scale This scale ranges from 0 to 5; toddlers may not be able to articulate numbers. • 10. The nurse is assessing for objective findings are associated with the patient•s pain level. Which findings are commonly associated with acute pain? Select all that apply: The patient is crying CorrectAn elevated blood pressure CorrectAn elevated heart rate CorrectDiaphoresis The patient states a pain level of 8 out of 10 on pain scale Vital signs stable CHAPTER 7 • 1. The nurse is assessing a patient who recently was diagnosed with a stroke. The patient is very emotional. In what part of the brain did the stroke most likely occur? Brainstem The brainstem regulates functions such as breathing and temperature control. Limbic system Correct Regulation of memory and basic emotion such as fear, anger, and sex drive are regulated by the limbic system, also called the emotional brain. Prefrontal lobe The prefrontal lobe is involved with memory. Cerebellum The cerebellum is involved with balance. • 2. The nurse is caring for a patient in the mental health facility who has a diagnosis of bipolar disorder. The nurse knows that this is because mental health is directly affected by the: Cerebral spinal fluid Cerebrospinal fluid (CSF) levels are important for brain and spinal regulation but are not directly involved with mental health. Neurotransmitters Correct The neurotransmitters involved include norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Thickness of the dura mater The dura mater is part of the lining of the brain called meninges. The pia mater The pia mater is the inner meningeal layer that supplies blood to the brain. • 3. An insufficient amount of the neurotransmitter GABA may result in . Depression GABA is an inhibitory neurotransmitter. Hallucinations Hallucinations may result from elevated levels of serotonin. Delusions Delusions may result from elevated levels of serotonin. Anxiety Correct GABA suppresses neurotransmission, which helps to control anxiety. • 4. The nurse is using the CAGE screening tool. This tool is used to screen for what? Sexual activity Sexual activity is addressed with interview questions. Depression The Beck depression inventory may be used to screen depression. Problem alcohol use Correct CAGE is one of the most popular screening tools used to assess alcohol use. Decreased mental status The Mini-Mental State is a common screening tool for mental status. • 5. The nurse suspects altered thought processes. Which findings might suggest an altered thought process? Select all that apply: CorrectDress or appearance Socioeconomic issues Cultural differences CorrectProblems articulating words CorrectTone of voice • 6. The nurse is performing a mental health assessment. Data collection for mental health assessment begins when the nurse: First sees the patient Correct The patient’s appearance, dress, and body posture are all important data to include in the mental health assessment. Obtains biographic data Biographic data is important, but it does not address the first impression. Begins the history The nurse should observe the patient before the history begins. Ends the examination Data collection usually ends at the end of the examination. • 7. The nurse notices that a patient has difficulty separating relevant from irrelevant information during a conversation. This patient is having difficulty with: Circumstantiality Correct This may not always be immediately apparent. Neologism Neologism is the use of a word or term with a meaning known only to the patient. Blocking Blocking occurs when the patient has difficulty articulating a response. Flight of ideas Flight of ideas is a disturbance in which thought patterns are vague and unfocused. • 8. The nurse is assessing the patient’s stressors. Which tool can be used to identify the degree of stressors a patient may be experiencing? CAGE CAGE is used to screen alcohol use. Holmes Social Readjustment Inventory Scale Correct This tool may help to identify a high-risk individual. AUDIT AUDIT is used to screen alcohol use. Mini-Mental State The Mini-Mental State is used to screen mental status. • 9. The nurse is planning to teach a group of patients stress reduction exercises to reduce the risk of depression. Which population group is at highest risk for depression? Males Depression occurs in women twice as often as it does in men. School-age children As a group, school-age children are at lower risk than other groups. Adolescents Correct Peer pressure and independence contribute to their increased risk. Individuals starting new careers Although some members of this group may suffer from depression, this is not considered a high-risk group. • 10. The nurse is obtaining the mental health history of a new patient. What should the nurse include in the mental health history? Select all that apply: CorrectThe patient’s description of self CorrectA past medical history CorrectThe current medications the patient is taking Cultural beliefs Spiritual beliefs CHAPTER 8 • 1. The nurse is assessing a patient’s nutritional status and suspects the patient needs more macronutrients. Which are considered macronutrients? Minerals Minerals are considered micronutrients. Vitamins Vitamins are considered micronutrients. Fats Correct Macronutrients include carbohydrates, proteins, and fats. Water Water is an essential dietary component, but it is not a macronutrient. • 2. The nurse is teaching a patient the importance of protein for healing. Which foods should the nurse include in the teaching plan? Fish Correct Fish contains all of the essential amino acids. Cereal Cereal is a starch. Bread Bread is a starch. Oatmeal Oatmeal is a grain and is considered a starch. • 3. The nurse is assessing a patient’s dietary intake to help the patient lose weight. What is the easiest way to assess the patient’s normal dietary intake? Comparing established eating habits with Dietary Reference Intakes Comparing what is recommended requires the patient to know what is recommended. Patients who need to lose weight may not have mastered this skill. Asking the nurse to fill out a food plan Filling out a food plan may not include the patient’s favorite foods. Comparing the recommended dietary allowances to the USDA MyPlate Utilizing the USDA MyPlate is a good intervention for implementation of the teaching plan. Asking the patient to do a 24-hour dietary recall Correct Having the patient do a 24-hour food recall will assist the nurse in collaborating with the patient to include foods that the patient enjoys. This will likely lead to adherence to the plan for two reasons: 1. The patient is involved in the plan. 2. The patient will not be deprived of favorite foods. • 4. The nurse suspects that the patient is suffering from malnutrition. Which laboratory test indicates a patient’s protein calorie status? Hemoglobin and hematocrit Hemoglobin and hematocrit screen for anemia resulting from dietary deficiency. Serum glucose levels Serum glucose levels are a reflection of carbohydrate metabolism. Lipid profile Lipid profile is an indication of fat (lipid) metabolism. Serum albumin Correct Serum albumin measures serum protein. • 5 The school nurse is assessing the nutritional status of a healthy adolescent. Which assessment will the nurse include in this assessment? Select all that apply: CorrectAnthropometrics CorrectBiochemical tests results CorrectClinical evaluation of diet Dietary assessment CorrectBody Mass Index (BMI) • 6. The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the nurse recommend for this patient? 2 to 3 Correct Between 2 and 3 servings is the recommended daily intake of dairy. 3 to 5 3 to 5 servings would be recommended for children and pregnant and lactating women. 5 to 6 5 to 6 servings of dairy is not a standard recommendation for any age category. 0 to 2 0 to 2 servings is not a standard recommendation for any age category. • 7. The nurse is assessing an elderly patient’s risk of nutritional deficiency. An important risk factor for nutritional deficiency in the elderly is: Increased blood pressure Elevations in blood pressure may be affected by nutritional intake but are not a risk for deficiency. Decreased activities of daily living Correct It is important to determine if the patient is capable of obtaining and preparing adequate food. An allergy to shellfish Many individuals have food allergies, but this in itself should not increase the risk of nutritional deficiency. Exercise pattern This may provide insight to the nurse’s activity level but not necessarily to the nutritional level. • 8. In which age group is skipping meals most commonly seen? School-age children The eating patterns of school-age children usually are influenced by their parents. Adolescents Correct Eating patterns may reveal poor eating habits associated with multiple school or athletic activities. Adults Although many busy adults may skip meals, as a group most adults eat consistently. Older adults Although some older adults may skip meals, as a group most eat consistently. • 9. According to the food plan, what represents one serving from the bread, cereal, and grain products group? 1 cup cooked rice One-half cup cooked rice represents one serving from this group. 6 soda crackers Three to four crackers represent one serving from this group. 1 hamburger bun One hamburger bun represents two servings from this group. 1 slice of bread Correct D. One slice of bread represents one serving from this group. A. One-half cup cooked rice represents one serving from this group. B. Three to four crackers represent one serving from this group. C. One hamburger bun represents two servings from this group. . • 10. The nurse is working with a patient to develop a nutritional plan for a patient newly diagnosed with diabetes. The nurse assesses what the patient’s food preferences are because: Food preferences can indicate a chronic disease that the nurse may be unaware of Chronic illness is not identified by a person’s food preference. Life expectancy can be predicted based on food preferences Longevity may be influenced by the foods consumed, but food preferences cannot be used to predict someone’s life span. Food preferences and dislikes have a strong influence on what a person eats Correct This becomes important with dietary teaching. A list of food preferences will help identify individuals who will not comply with special diets Dietary compliance cannot be determined based on food preference alone, but it helps to identify those who may struggle with special diets. CHAPTER 9 • 1. The nurse knows that the functions of the skin include: Select all that apply: CorrectSensory input CorrectProtection CorrectProduction of vitamin D CorrectTemperature regulation Production of vitamin C Sensory output • 2. The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers that react to touch, pain, and temperature? The epidermis The epidermis is the outermost skin layer; no sensory fibers are found here. The dermis Correct The dermis contains the nerves and vascular supply. The hypodermis The hypodermis contains connective tissue and subcutaneous fat and is not used for sensation. The subcutaneous tissue Subcutaneous tissue is found in the hypodermis. • 3. The nurse is performing a skin assessment and finds that the patient has milia. In which age group would this be an expected finding? Newborns Correct Milia are small white papules found on the face of a newborn infant. Young children Milia are not found in young children. Adolescents Milia are not found in adolescents. Older adults Milia are not found in older adults. • 4. A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the nurse what could be causing this? The nurse’s best response is: “Macules need to be watched closely for signs of skin cancer.” Macules are not considered a risk factor for skin cancer. “Macules are warts and should be removed.” Macules are not warts. “Macules are freckles are considered normal on the skin.” Correct Another name for macules is freckles. Freckles are considered normal and benign. “You have an infection and will need an antibiotic.” Macules are not considered infectious. • 5. The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n): Yellowish-green skin This is how jaundiced skin may appear. Deeper tone of brown or purple Erythema may appear this way. Ashen gray color to the skin Correct This is easiest to see in the oral mucous membranes, nail beds, and conjunctiva of the eye. Cluster of dark spots over the skin surface This is how ecchymosis may appear. • 6. The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? The width of the nail base The width is not an indicator of clubbing. The color of the nail The color of the nail may indicate cyanosis but not clubbing. The thickness of the nail The thickness of the nail may be affected by trauma, fungal infection, or poor circulation. The angle of the nail base Correct Clubbing is associated with an increased nail bed angle. • 7. A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further investigate a lesion? The lesion is dark brown. This color is common for nevi. The lesion has been present for 20 years. This is only a concern if the lesion has recently changed in size or appearance. The lesion bleeds easily when it is touched. Correct A lesion that bleeds easily could be malignant. The lesion is slightly raised and circumscribed. Well-circumscribed lesions tend to be benign lesions. • 8. The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected finding? Newborns Seborrheic keratosis is not seen in newborns. Young children Seborrheic keratosis is not seen in young children. Adolescents Seborrheic keratosis is not seen in adolescents. Older adults Correct These lesions are fairly common in older adults. • 9. The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What would the nurse include as the most common cause of skin lesions for this age group? Communicable disease and bacterial infection Correct These spread quickly among those in this age group. Changes in skin turgor and skin tone There are no significant changes in skin tone or turgor. Maturation of melanocytes, causing changes in skin color This does not produce lesions. Skin inflammation from sebaceous gland activity This describes acne and is common among adolescents. • 10. The nurse is assessing a patient’s skin turgor. Skin turgor is assessed by: Auscultating the skin to note the presence of motility sounds This is never done. Pressing on the skin and observing the depression This might be done to assess for pitting edema. Stretching the skin and observing for a degree of flexibility This is not done. Pinching the skin and watching the skin return to place Correct The skin under the clavicle is frequently used. CHAPTER 10 • 1. A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve? The tympanic membrane The tympanic membrane separates the ear canal from the middle ear. The ossicle Correct Three tiny bones make up the ossicle. This structure transmits sound. The organ of Corti The organ of Corti is located within the cochlea, the coiled structure within the inner ear. The tragus The tragus is a protuberance on the external ear. • 2. The nurse is assessing a patient’s mandible. The area between the sternocleidomastoid muscles and the mandible is anatomically known as the: Anterior neck The anterior part of the neck is part of this anatomic location. Thyroid The thyroid is part of the anterior triangle. Anterior triangle Correct This is fairly well defined, especially on thin individuals. Cervical lymph nodes of the neck The cervical lymph nodes run anteriorly and posteriorly. • 3. The nurse is assessing a patient’s optic disc. What instrument would be best for this assessment? The optic disc is viewed with an ophthalmoscope. Correct The optic disc is viewed with an ophthalmoscope. The optic disc is viewed with a stethoscope. A stethoscope is used to auscultate for heart, lung, and vascular sounds. The optic disc is viewed with an otoscope. The otoscope is used to view the ear structures. The optic disc is viewed by the naked eye. The nurse would not be able to see the optic disc with the naked eye. • 4. The nurse is aware that the greatest physical variation of ears among individuals of different races is: The size of the ear The size of the ear may vary slightly but is not affected by race. Hearing acuity Hearing acuity is not affected by ethnicity. Consistency and color of cerumen Correct Asian and American Indian and Alaska natives have sparse, dry, flaky cerumen, whereas white and dark-skinned races have moist, sticky, and dark cerumen. The length of the auditory canal The length of the ear canal for all adults is approximately 2.5 cm. • 5. The nurse suspects that a female patient is having trouble with the thyroid when the patient answers yes to which question? “How much alcohol do you drink?” Patterns of alcohol intake are not relevant to the thyroid. “Have you noticed a change in your level of energy?” Correct Changes in thyroid function may cause symptoms of hyperactivity or fatigue. “Do you have headaches?” Thyroid problems are not generally associated with headaches. “Are you currently menstruating?” Menstruation does not affect thyroid function. • 6. The nurse is treating a patient for a nosebleed. The patient complains of frequent nosebleeds. What could be a possible cause of the nosebleeds? Excessive cilia Excessive hair inside the nose will not cause nosebleeds. Tobacco use Tobacco does not typically contribute to nosebleeds. Snorting cocaine Correct Cocaine is an irritant to the nasal mucosa. Further assessment would be required to rule this out. Hypotension Hypertension may be associated with nosebleeds. • 7. The nurse is assessing a patient for confrontation. The confrontation test assesses: Visual acuity This is assessed with eye charts. Peripheral vision Correct The examiner must have normal peripheral visual fields to do this. Extraocular muscle movement This is assessed by asking the patient to follow the six cardinal fields of gaze. Red reflex This is assessed with an ophthalmoscope. • 8. The student nurse is learning how to use the ophthalmoscope. When performing an ophthalmoscopic examination, examine the patient’s right: Eye with your right eye and the patient’s left eye with your left eye Correct This may seem awkward, but it allows the examiner to get close to the eye. Eye with your left eye, and the patient’s left eye with your right eye It is hard to get as close to the patient’s eyes when you have facial features such as the nose getting in the way. And left eyes with your dominant eye The examiner needs to be close to both eyes. And left eyes with your nondominant eye The examiner needs to be close to both eyes. • 9. The nurse is documenting in the chart. For documentation purposes, which term is used to describe a head that is of average size and shape? Normocephalic Correct This term refers to a head of average size and shape. Microcephalic This term refers to an abnormally small head. Macrocephalic This term refers to an abnormally large head. Hydrocephalic This term refers to a condition in which excessive fluid accumulates, causing an abnormally large head. • 10. The nurse is asking the patient to stick out his tongue and move it back and forth. Which cranial nerve is the nurse testing? Hypoglossal nerve (CN XII) Correct The examiner should note smooth and coordinated movement. Vagus nerve (CN X) This can be assessed with a gag reflex. Facial nerve (CN VII) This is tested by asking the patient to smile, frown, etc. Olfactory nerve (CN I) This is tested by asking the patient to identify a smell. CHAPTER 11 • The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ? Pectoral muscles External intercostal muscles Correct Abdominal muscles Scalene muscles • 2. A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects: A viral infection Tuberculosis Pulmonary edema Bacterial pneumonia Correct • 3. The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding? Chronic obstructive pulmonary disease Correct Pneumothorax Infant respiratory distress syndrome Atelectasis • 4. The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect? Tuberculosis Pneumonia Croup Asthma Correct • 5. The nurse is palpating a patient’s chest wall. What can be accomplished with palpation of the chest? Approximation of lung size Determination of oxygenation Assessment of equal chest expansion Correct Identification of lung sounds • 6. The nurse percusses a patient’s chest and feels dullness. The nurse suspects which diagnosis? Emphysema Pneumonia Correct Bronchiectasis Chronic obstructive pulmonary disease (COPD) • 7. A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? Consolidation in alveoli Narrowed airways Correct Sputum in the bronchi Fluid in the alveoli • 8. A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates: A normal finding Correct Pneumonia Lung cancer Pleural effusion • 9. The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean? The patient may have a pleural effusion. Correct The patient may have a pneumothorax. Asymmetric findings are common in well-conditioned adults. This is a normal finding because the right lung is larger than the left lung. • 10. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what? Select all that apply: Adventitious sounds and limited chest expansion Increased tactile fremitus and dull percussion tones CorrectMuffled voice sounds and symmetric tactile fremitus Absent voice sounds and hyperresonant percussion tones CorrectSymmetric chest CorrectResonant percussion tones CorrectExpansion muffled voice sounds CHAPTER 12 • 1. The nurse is listening to a patient’s heart and hears an S2 sound. The S2 heart sound is caused by the: Opening of the aortic and pulmonic valves Opening of the mitral and tricuspid valves Closing of the aortic and pulmonic valves Correct Closing of the mitral and tricuspid valves • 2. The nurse assesses a pulse at 3+ amplitude. Which word best describes a pulse with 3+ amplitude? Diminished Normal Full volume Correct Bounding • 3. A patient reports that he has intermittent chest pain. Which is the most appropriate question to ask next? “Do you work in a stressful environment?” “Have you told your physician about the chest pain?” “What other symptoms do you have when the chest pain occurs?” Correct “Do you have high cholesterol levels?” • 4. The nurse is percussing the heart. Percussion of the heart could be performed to: Estimate the heart’s size and borders Correct Determine fluid levels in the heart Locate the presence of a murmur Identify congenital heart defects • 5. A patient complains of chest pain. Which report made by a patient would suggest to the nurse that the chest pain is cardiac in origin? “My chest hurts every time I cough.” “My chest feels really tight and heavy.” Correct “I have sharp pains in my chest when I eat raw vegetables.” “I fell on some ice yesterday. Today, my chest hurts when I breathe.” • 6. A patient has 3+ pitting edema in her feet and ankles. The nurse suspects: The patient has a heart murmur The patient has excess fluid in the interstitial space Correct The patient is having a myocardial infarction The patient has elevated cholesterol levels • 7. A patient reports shortness of breath with a gradual onset. The nurse suspects: Heart failure Correct Dysrhythmia Deep vein thrombosis Myocardial infarction • 8. A patient reports leg and foot pain with activity that resolves with rest. With what type of problem is this consistent? Arterial insufficiency Correct Leg edema Venous thrombosis Hypertension • 9. The nurse is assessing a patient’s dorsalis pedis pulse. What is the primary reason for this assessment? The patient’s heart rate Perfusion to the foot Correct Sensation to the foot Reflexes within the foot • 10. The nurse is palpating a patient’s pericardium. What may be detected by palpating the pericardium? An inflammation of the heart An increased heart size An increase in cardiac output A thrill Correct