Test Bank - Health Assessment for Nursing Practice, 6th Edition (Wilson, 2017), Chapter 1-17, 22-24

Wilson and Giddens HA review questions Ch. 1-17, 22-24 A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission? 1 A comprehensive assessment 2 A problem-based health assessment 3 An episodic assessment 4 A screening assessment for colorectal cancer - ANSWER 1 A comprehensive assessment After collecting data, the nurse begins data analysis with which activity? 1. Documenting information from the history 2. Organizing the data collected 3. Reporting data to other care providers 4. Recording data from the physical examination - ANSWER 2 Organizing the data collected Which situation illustrates a screening assessment? 1. A patient visits a clinic for the first time and the nurse completes a history and physical examination. 2. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels. 3. A nurse at an urgent care center checks the blood pressure, pulse, temperature, and respirations of a patient reporting leg pain. 4. A patient with diabetes mellitus comes to the laboratory to get her blood glucose tested prior to a visit with a health care provider. - ANSWER 2. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels. The nurse documents which information in the patient's history? 1. The patient is scratching his left arm. 2. The patient's skin feels warm. 3. The patient reports itching of her eyes. 4. The patient's temperature is 100°F. - ANSWER 4. The patient's temperature is 100°F. 5. Select the example given below that represents information a nurse collects from a patient during a physical examination. 1. Shiny skin and lack of hair found on lower legs 2. Concerned about lack of money to pay for prescriptions 3. Complains of tingling in both feet while sleeping 4. Family history of colon and breast cancer - ANSWER 1. Shiny skin and lack of hair found on lower legs 1. The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? 1. "How often do you visit the medicine man for your health care?" 2. "Tell me about your health care beliefs and practices." 3. "Many Navajo people are afraid of hospitals. Are you afraid?" 4. "Have you ever had a physical examination with a physician or a nurse practitioner?" - ANSWER 2. "Tell me about your health care beliefs and practices." 2. The nurse is conducting an interview with Jeremy, a 17-year-old accompanied by his mother. Which statement made by the nurse is an age-appropriate adjustment when conducting a health history with an adolescent? 1. "Jeremy, do you have a girlfriend, and if so are you sexually active yet?" 2. "Mrs. Williams, is your son sexually active yet?" 3. "Jeremy, how do you incorporate safe sex practices into your daily life?" 4. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy?" - ANSWER 4. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy?" During an interview, an elderly patient tells the nurse that she has periodic problems in keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom analysis is the nurse pursuing with this question? 1. Severity 2. Frequency 3. Aggravating factors 4. Location - ANSWER 3. Aggravating factors Which communication technique conveys genuine interest in what the patient has to say? 1. Active listening 2. Sitting close to the patient 3. Maintaining professional dress and conduct 4. Holding the patient's hand during the interview - ANSWER 1. Active listening 5. A 62-year-old patient tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patient's statement? 1. "Do you avoid taking drugs because of bad experiences?" 2. "Which medications have you taken in the past?" 3. "That is hard to believe. Most men your age take medications." 4. "Do you use over-the-counter medications or herbal preparations?" - ANSWER 4. "Do you use over-the-counter medications or herbal preparations?" The nurse is caring for a patient with a femur fracture. An immobilization device is used to maintain the alignment of the femur. The nurse palpates the top of the foot to make which determination?1. Amount of drainage from the wound 2. Adequacy of blood perfusion to the foot 3. Presence of air in the underlying tissue 4. Range of motion to the foot - ANSWER 2. Adequacy of blood perfusion to the foot Auscultation is a component of which examination technique? 1. Blood pressure measurement 2. Visual acuity 3. Examination of the ears 4. Measurement of oxygen saturation - ANSWER 1. Blood pressure measurement Which infection control intervention is most frequently applied? 1. Wearing gloves 2. Using masks 3. Wearing eye protection 4. Hand hygiene - ANSWER 4. Hand hygiene While examining a patient with an infected abdominal incision, the nurse notices that it is very malodorous. Which technique does this represent? 1. Inspection 2. Palpation 3. Auscultation 4. Percussion - ANSWER 1. Inspection The nurse obtains vital signs on a 42-year-old man having his annual physical examination. He has no medical conditions and states that his health is excellent. Using an automated blood pressure device, his blood pressure is measured as 62/40. Which action by the nurse is most appropriate? 1. Obtain a different cuff and take the blood pressure again. 2. Take the blood pressure again using the auscultation method. 3. Place the patient in a supine position and take the pressure on the leg. 4. Record the blood pressure and continue with the examination. - ANSWER 2. Take the blood pressure again using the auscultation method. Which set of vital signs should the nurse recognize as out of the expected range? 1. 42-year-old man: BP, 114/82, pulse, 74 beats/min, respiration, 16 breaths/min, temperature, 36.8° C 2. 11-year-old girl: pulse, 88 beats/min, respiration, 22 breaths/min, temperature, 36.7° C3. 3-year-old boy: pulse, 130 beats/min, respiration, 44 breaths/min, temperature, 36.7° C 4. 1-month-old girl: pulse, 120 beats/min, respiration, 42 breaths/min, temperature, 36.7° C - ANSWER 3-year-old boy: pulse, 130 beats/min, respiration, 44 breaths/min, temperature, 36.7° C