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test bank for health assessment for nursing practice 7th edition by wilson-1-50.pdf

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Health Assessment for Nursing Practice, 7th Edition focuses on what you need to know, providing easy-to-understand guidelines for an effective physical examination as well as preparation for the Next Generation NCLEX® Examination (NGN). New to this edition is a greater emphasis on normal findings and less on abnormal findings, new LGBTQ+ Considerations boxes, and new NGN Exam-style case studies. Written by noted nursing educators Susan Fickertt Wilson and Jean Health Assessment for Nursing Practice, 7th Edition focuses on what you need to know, providing easy-to-understand guidelines for an effective physical examination as well as preparation for the Next Generation NCLEX® Examination (NGN). New to this edition is a greater emphasis on normal findings and less on abnormal findings, new LGBTQ+ Considerations boxes, and new NGN Exam-style case studies. Written by noted nursing educators Susan Fickertt Wilson and Jean Foret Giddens, this book has everything you need to conduct and document an accurate assessment, succeed on the NGN, and prepare for clinical practice.Health Assessment for Nursing Practice, 7th Edition focuses on what you need to know, providing easy-to-understand guidelines for an effective physical examination as well as preparation for the Next Generation NCLEX® Examination (NGN). New to this edition is a greater emphasis on normal findings and less on abnormal findings, new LGBTQ+ Considerations boxes, and new NGN Exam-style case studies. Written by noted nursing educators Susan Fickertt Wilson and Jean Foret Giddens, this book has everything you need to conduct and document an accurate assessment, succeed on the NGN, and prepare for clinical practice.Health Assessment for Nursing Practice, 7th Edition focuses on what you need to know, providing easy-to-understand guidelines for an effective physical examination as well as preparation for the Next Generation NCLEX® Examination (NGN). New to this edition is a greater emphasis on normal findings and less on abnormal findings, new LGBTQ+ Considerations boxes, and new NGN Exam-style case studies. Written by noted nursing educators Susan Fickertt Wilson and Jean Foret Giddens, this book has everything you need to conduct and document an accurate assessment, succeed on the NGN, and prepare for clinical practice.Foret Giddens, this book has everything you need to conduct and document an accurate assessment, succeed on the NGN, and prepare for clinical practice.

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Related topics:
Health Assessment • Nursing Practice • Educational Test Banks • Physical Examination
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson Chapter 1 - 24
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD Chapter01:IntroductiontoHealthAssessment MULTIPLE CHOICE 1. Aigpatientigcomesigto the emergencydepartmentigandigtellsthe triage nursethatigheis “havinga heart attack.” What isigthe nurse’stop priorityatigthistime? a. Determinethepatient’spersonalig data andi g insu rance coverage. b. Ask the patientigtotake a seatiginigthewaitingro omiguntil hisname iscalled. c. Requestigthata nursecollectigdataigfor aig c omprehensive history. d. Ask aignurseto startigafocusedigassessmenti g o fthispatient now. The nurse needs to beginigan assessment as soon as possible that is focused on this patient’si g ca rdiovascular system. The type of health assessment performed by the nurse is also driveni g by patient need. Personal data and insurance information will be obtained, but inigthis situation, t hese data canigwaitiguntil after the patient is assessed. Based also on Maslow’s hierarchy of ne eds, physiologic needs take precedence. Rather thanigasking the patient to wait, the nurse nee ds to beginigdata collection, such as vital signs, immediately to determinethe patient’s health status. Complications can be prevented if anigimmediate assessment is made to analyze the pa tient’s symptoms. A comprehensive history is notigindicated inigthis situation at this time. Som e subjective data will be collected, suchigas allergies andigmedical history relatedigto cardiovasc ular disease. Eyes, ears, or a complete musculoskeletal or mental healthassessment is not a p riorityat thisigtime. DIF: Cognitive Level: Apply REF: Box 1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment:Managementof Care:Establishin gPriorities 2. Which situationigillustratesiga screeningassessment? a. A patient visits anigobstetric clinic for the firs tig timeandig the nurseconductsaigdetailedi g history and physicaligexamination. b. Aighospital sponsorsa health fair atigalocalig mall and provides cholesterol and bloodigp ressure checksto malligpatrons. c. The nurse inanigurgent care center checksi g t he vital signs of aigpatient who is complain ingofiglegigpain.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igA A healthigfair at a localigmall that provides cholesterol and blood pressure checks is an exampl e of a screening assessment focusedigonigdisease detection. A detailed history and physical exa minationconductedigduringiga first- time visit to anobstetric clinic is anexampleof a comprehensive assessment. Assessing a pati ent complaining of leg painiginigthe triage area of anigurgent care center is anigexample ofiga prob lem- based/focused assessment. A patient’s return appointment 1 month after today’s office visit t o reportigfasting blood glucose levelsisanigexample ofiganigepisodic or follow-up assessment. DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionigandigMaintenance: HealthScreening 3. For whichigpersonisa screeningassessment indicated? a. Thepersonigwho hadabdominal surgery yesterday b. The personigwhois unaware ofighisig highi g s erumigglucose levels c. The personigwho isigbeingadmitted to aig l ong-termigcare facility d. The personigwho isbeginning rehabilitationi g af ter a knee replacement A screening assessment is performed for the purpose of disease detection. In this case thisp erson may have diabetes mellitus. A shift assessment is most appropriate for the personigwh o is recoveringiginigthe hospital fromigsurgery. A comprehensive assessment is performedi g duri ngigadmissionigto a facility to obtain a detailed history and complete physical examination. A n episodic or follow- up assessment is performed after knee replacement toevaluate the outcome ofigthe procedure . DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gigPriorities 4. For whichigpersonigisaigshiftigassessmentigindicated? a. Thepersonigwho hadabdominal surgery yesterday b. The personigwhoisunaware of hishighs erumigglucose levels c. The personigwho isbeingadmitted to a long-termcare facility d. The personigwhoisbeginningrehabilitationi g a fter aigknee replacement A shiftigassessment is most appropriate for the person who is recovering in the hospital fromi g s d. Aigpatient newly diagnosed withigdiabetesig mellitus comes to test his fastingigblood g lucoselevel. ANSWER:igB
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE urgery. Aigscreening assessmentigis performed for the purpose ofigdisease detection, in this case diabetesmellitus. Aigcomprehensive assessmentisperformedigduringigadmissionigtoa
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igC ANSWER:igD facility to obtain a detailed history and complete physical examination. An episodic or foll ow- up assessment isperformedigafter kneereplacement to evaluate the outcome oftheprocedur e. DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 4TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment:Managementof Care:Establishin gPriorities 5. For whichigpersonigisaigcomprehensive assessment indicated? a. Thepersonigwho hadigabdominaligsurgery yesterday b. The personigwhois unaware ofighishighi g s erumigglucose levels c. The personigwho isbeingadmitted to aig l ong-termigcare facility d. The personigwho isbeginningrehabilitationi g af ter a knee replacement Aigcomprehensive assessment isperformed duringadmissiontoa facilityto obtain a detailed history and complete physicaligexamination. Aigshift assessment is most appropriatef or the person who is recovering in the hospital from surgery. A screening assessment is perf ormed for the purpose of disease detection, inigthis case diabetes mellitus. Anigepisodic or fol low- up assessment is performed after knee replacement to evaluate the outcome of the procedur e. DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 6. For whichigpersonisani g episodic orfollow-upassessment indicated? a. Thepersonigwho hadabdominal surgery yesterday b. The personwho isunaware ofhishighs erum glucose levels c. The personigwho isbeingadmittedigto a long-termigcare facility d. The personigwho isbeginningrehabilitationi g af ter a knee replacement Anigepisodic or follow- up assessment is performed after the knee replacement to evaluate the outcome of the proce dure. A shift assessment is most appropriate for the person who isrecovering in the hospital fromigsurgery. A screening assessment is performed for the purpose ofigdisease detection, inigth isigcasediabetes mellitus. Aigcomprehensive assessment is performed during admissionigto a fa cility to obtain a detailed history and complete physicali g examination. DIF: Cognitive Level: Understand REF: Boxig1-
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE 3 | p. 3TOP: NursingigProcess: Assessment
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igD MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 7. Whichisanexample ofdata a nurse collectsduringa physicale xamination? a. The patient’si g lackigofighairand shinyskini g o ver bothigshins b. The patient’sstatedigconcernabout lackigofmo neyfor prescriptions c. Thepatient’scomplaintsofig tinglingi g s ensationsinigthe feet d. Thepatient’smother’s statementsthatig thep atientisverynervouslately The lack of hair andigshiny skin over bothigshins are objective data or signs thatigare part of the physical examination. Apatient’sconcernsabout lackigof moneyare subjective dataigandi g are pa rt of the health history. A patient’s complaints ofigtinglingigsensations in the feetigare subjective dataigandigare part of the health history. A patient’s family statements are consideredigsecondar ydata, are subjective data, and are part ofigthe healthhistory. DIF: Cognitive Level: Apply REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs:Physiologic Integrity: Reductionigof RiskigPotential: SystemSpecific Assessments 8. The nursedocumentswhichinformationiginigthe patient’shistory? a. Thepatient’sskinigfeelswarmtothe touch. b. The patientigisscratchinghisigarm. c. Thepatient’stemperatureis100°F. d. Thepatientcomplainsofigitching. A patient’s complaint of itchingigis subjective information, whichigmeans it is a symptom an d is documented in the history. The patient’s warm skinigis objective information gathered b ythe nurse throughig palpation, isalso a sign, andigisdocumentediginig the physicali g examination. The patient’s scratchingigis objective information gathered by the nurse throughigobservation , is also a sign, andigis documented inigthe physicaligexamination. The patient’s elevated temp erature is objective information gathered by the nurse through measurement, isigalso a sign, andigisdocumented inigthe physical examination. DIF: Cognitive Level: Apply REF: p. 1 | p. 2 andigBox 1- 2TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 9. Whichpatient informationig doesthe nurse document inthe patient’sphysicali g as sessment? a. Slurredigspeech b. Immunizations c. Smoking habit d. Allergies
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igD ANSWER:igA Slurredigspeech shouldigbe noticed by the nurse andigdocumented as objective data in the physi cal assessment. Data on immunizations are collected fromigthe patient, are subjective, and do cumented inthe history. A smokingighabit isinformationthat comes fromig the patient,i g makingigit subjective data that is documented in the history. Allergies are information that come fromigt he patient, makingit subjective data that isdocumented inigthe history. DIF: Cognitive Level: Apply REF: p. 1-2 andigBox 1- 2TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 10. Aftercollectingigthe data,the nurse beginsdataiganalysiswithigwhichigaction? a. Clusteringigdata b. Documentingigsubjective data c. Reportinginformationigtoother healthigteamig members d. Documentingigobjective information After collectingdata, the nurse organizesor clustersigthe data so that the problemsigappearmore clearly. To cluster data,the nurse interpretsigthe assessmentigdataigcollected. Documenting subjective dataigis necessary for the medical record, but does notigprovide analy sis. Before reporting data to healthigteam members, the nurse clusters and interprets data. Doc umentingigobjectivedata isnecessaryfor the medical record, but does not provideanalysis. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.4 MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: EstablishingPriorities 11. Whichactivityillustratesthe concept ofprimaryprevention? a. Monthlybreast self-examination b. Annualigcervicalig(Papanicolaouigtest) examination c. Educationabout livingwithigasthma d. Exercisingthree timesigaigweek Exercising is an example of primary prevention that prevents disease from developingigby m aintaining aighealthy lifestyle. Monthly breast self- examination is an example of secondary prevention and screening efforts to promote early d etectionigof disease. Annual cervical (Papanicolaou test) examinationigis an example of secon dary prevention and screening efforts to promote early detection of disease. Teaching a patie nt how to live withi g a chronic disease such as asthma is an example of tertiary prevention dire ctedigtowardigminimizingigthe disability from chronic disease andighelping the patientigmaximiz e his or herhealth. DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5- 6TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthigPromotionigPrograms
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igC ANSWER:igA ANSWER:igB 12. Aignurse is teaching a patientighow to manage chronic obstructive pulmonaryd isease (COPD). Thisinterventionisanigexample of whichiglevel ofighealthigpromotion? a. Primaryprevention b. Secondaryprevention c. Tertiaryprevention d. Riskigfactor prevention Teachingiga patientighow to live withiga chronic disease is anigexample of tertiary prevention dir ectedigtowardigminimizing the disability fromigchronic disease and helpingigthe patient maximiz e his or her health. The focus ofigprimary prevention is to prevent aigdisease from developingigb y promoting aighealthy lifestyle. Secondary preventionigconsists of efforts to promote early det ection of disease. Risk factor prevention is part of primary prevention thati g focuseson preventi ngdisease bymanagingrisk factors. DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5- 6TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthPromotionigPrograms 13. Whichigactivityillustratesigthe concept of secondaryprevention? a. Annualigmammogram b. Nutritionigclassesoniglow-fatcooking c. Educationigoniglivingwithigdiabetes mellitus d. Cardiac rehabilitationigafter coronaryarteryby passsurgery A mammogram screens for breastigcancer and is an example of secondary prevention to pro mote early detection of disease. Nutrition classes are an example of primary preventionto pr event a disease fromigdeveloping by promoting a healthy lifestyle. Education about diabetes mellitus is anigexample ofigtertiary prevention directed towardigminimizing the disability fromig chronic disease and helping the patient maximize his or her health. Cardiac rehabilitationigaft er coronary artery bypass surgery is an example of tertiary preventionigdirected towardigmini mizing the disability fromigchronic disease andighelping the patientigmaximize hisigor her healt h. DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5- 6TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthigPromotionPrograms 14. Aigcommunityorganizationigsponsors a healthigfair to increase awareness ofcoloni g ca ncer. At the health fair, colorectal cancer screening kits are distributed, andighealth care profe ssionals answer questions, take blood pressure, andigdistribute literature. What level ofi g health preventionisbeingimplemented bythiscommunityorganization? a. Primary b. Secondary c. Tertiary d. Riskigfactor Secondary prevention consists of screening efforts to promote early detectionigof disease — in this scenario, colorectal cancer andighypertension. Primary preventionigis focusedigon preve ntingigdisease fromigdevelopingigthroughigthe promotionigofiga healthylifestyle. Tertiary
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE prevention is directed toward minimizing the disability from chronic disease and helping the patient maximize hisor her health. Riskigfactor preventionig isig part ofprimary preventioni g that foc usesigonigpreventingdisease bymanagingrisk factors. DIF: Cognitive Level: Apply REF: Table 1-1 | p. 5- 6TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthPromotionigPrograms Pow er ed by TCPDFig (w w w.t p cd f.igo rg )
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER: A ANSWER:igB Chapter02:Obtaining a HealthHistory MULTIPLE CHOICE 1. Which statement or question does the nurse use during the introductionig phase ofigthe interview? a. “I’mighereto learnmoreabout thepaini g y ou’re experiencing.” b. “Canyouigdescribe thepaini g that you’rei g e xperiencing?” c. “Iigheardigyou saythat the painigisig‘alligover’your body.” d. “What relievesthe painigyouigare having?” “I’mighere to learn more about the painigyou’re experiencing” is an example of the introductio n phase a nurse may use to explainigthe purpose ofigthe interview to a patient. “Can you descri be the painigthat you’re experiencing?” is an example of part of a symptomi g analysisthat occur sini g thediscussionigphase.“Iheard you saythat the painigis‘alligover’ your body” is an example o f a summary statement by the nurse that occurs in the summary phase. “What relieves the pai n you are having?” is an example of part of a symptom analysisthat occursinigthe discussionigp hase. DIF: CognitiveLevel: Apply REF: Boxig2-1 | p. 8- 9TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 2. Which statement isappropriate to use whenigbeginning aninterview withai g n ew patient? a. “Have youigeverbeenigapatient inthisclinicbef ore?” b. “Whatigis your purpose for comingigtothec linictoday?” c. “Tellmeaiglittle about yourselfand yourfamil y.” d. “Did youighave anydifficultyfindingthec linic?” “What is your purpose for comingigto the clinic today?” is anigopen- endedigquestion that focuses onigthe patient’sreasonigfor seeking care. “Have youigever been aigpa tientiginig thisclinici g before?” is aigclose- endedigquestion thatigyields a “yes” or “no” response. This questionigmay be askedigon the firstigv isit, but not as an openingigquestion for a health interview. “Tell me a little aboutigyourselfigandig your family” is an open- endedigquestion, but itigis too general, andigiti g isatigleastig twoquestions: one aboutig thepatientigandig a notheraboutigthefamily. “Didigyou have
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igC ANSWER:igD any difficulty finding the clinic?” is a socialigquestion and does not focus onigthe patient’si g p urpose for the visit. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.8 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 3. Whichigstatementigbythe nursedemonstratesa patient-centerediginterview? a. “Iigneedigto complete this questionnaire ab out your medical and familyhistory.” b. “The hospital requires me to complete this assessment assoonaspossible.” c. “Tellmeaboutthe symptoms you’vebeeni g h aving.” d. “I’vehadigthesame symptomsthatigyou’ved escribed.” “Tell me aboutigthe symptoms you’ve been having” focuses onigthe needs of the patient so tha t the patient is free to share concerns, beliefs, andigvalues inighis or her own words. “I need to complete this questionnaire about your medicaligandigfamily history” focuses on thenurse’s n eed to complete the assessment rather than the needs of the patient. “The hospitali g requiresm e tocomplete thisassessment as sooni g aspossible” focusesoni g the nurse’sneedigtoi g meet hospital requirements rather than the needs of the patient. “I’ve hadigthe same symptoms thatigyou’ve described” focusesonthe nurse rather thanigonigthe patient. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.8 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 4. Whichquestionigisanigexample ofan open-ended question? a. “Have youexperiencedthispainigbefore?” b. “Doyouighave someone tohelp youig ati g h ome?” c. “Howmanytimesa daydo you use your inhaler?” d. “Whatigwere youigdoingwhenyou felt thep ain?” “What were you doingigwhen youigfelt the pain?” is a broadly stated questionigthat encourage s a free-flowing, openigresponse. “Have youigexperienced this painigbefore?” is closed- ended, which can obtainiga “yes” or “no” answer to the questionigwithout any additionaligdata . “Do you have someone to help youigat home?” is closed- ended, which canobtain a “yes” or “no” answer to the questionigwithout any additional data. “How many times a day do you use your inhaler?” is closed- ended, which can obtainiganiganswer of a specific number without anyadditional data.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD ANSWER:igB DIF: Cognitive Level: Understand REF: pp.10- 11TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 5. Aig nurse suspectsa femalepatientigisa victimigofig physicalabuse. Whichi g re sponse ismostlikelyto encourage the patient toconfide inthe nurse? a. “You’ve gotigaighugebruiseonigyour face. Did your husband hit you?” b. “That bruise looks tender. Iigdon’t know howpeople canigdo that toone another.” c. “Ifyourboyfriendighitigyou, youigcaniggetar estrainingorder against him.” d. “I’ve seenigwomenigwho have been hurtigbyb oyfriends or husbands. Does anyone hit y ou?” “I’ve seen women who have been hurt by boyfriends or husbands” is an example ofiga techniq uereferredto asig“permission giving” inigwhichigthe nurse communicatesthatitis safe to discuss uncomfortabletopics. “You’vegot a hugebruiseonig your face. Did your husbandi g hit you?” as sumes that domestic violence did occur, and the comment does not encourage the patient to divulge additional information. “That bruise looks tender. I don’t know how people can do t hat to one another” assumes that domestic violence did occur, and the comment does not enc ourage the patient to divulge additional information. “Ifigyour boyfriend has hit you, you can get aigrestraining order againstighim” assumes thatigdomestic violence did occur, andigthe comm ent does not encourage the patient to divulge additional information. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 10 MSC: NCLEXigPatient Needs: Psychosocial Integrity: Abuse/Neglect 6. Which technique used by the nurse encourages a patient to continue talkingi g d uringiganiginterview? a. Laughingandigsmilingigduringigconversation b. Usingphrases suchigas“Go on,” andi g “ Then?” c. Repeating what the patientigsaid, but using different words d. Askingigthe patient to clarifya point Using phrases suchigas “Go on” and “Then?” encourages the patient to continue talking. La ughing and smiling during conversationigmay show attentiveness during the interview,but d oes notencourage more talking. Rephrasingigwhat the patient has said isigrestatement.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igA Itconfirmsyourinterpretationofwhatigtheysaid, butdoesnot encourage additionaligtalking.Asking the patient to clarify a point is done when the information is conflicting, vague, or ambiguous. DIF: Cognitive Level: Remember TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 7. During the history,igthe patient states that she does not use many drugs.ig What isthe nurse’sappropriate response tothis statement? a. “Tell me aboutigthe drugs youigare usingig currently.” b. “Tosome people sixor sevenigisnotig many.” c. “Do you meanigprescriptiondrugsor illicitig drugs?” d. “Howoftenare youusingthese drugs?” “Tell me aboutigthe drugs youigare using currently” is anigopen- endedigquestion thatigallows patients to provide further data. “To some people sixigor seven is not many” is a commentigthat does notigaskiga question or obtain usefuligdata. “Do you meanigpr escriptionigdrugs or illicit street drugs?”isigaigclosed- endedigquestionigthatigyieldsdataigabout the typeofigdrugsi g usedi g only. “How often are you using th ese drugs?” asks about frequency of drug use, which is not useful until the drugsare known. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 8. A nurse is interviewingiga patient who was diagnosedigwith type 2 diabetes me llitus 6 months ago. Since that time, the patient has gained weight and her blood glucoselevel sigremain high. The nurse suspectsthatigthe patient isignoncompliant withigher diet. Whichresp onse bythe nurse enhancesdataigcollectioniginigthis situation? a. “Tell meabout what foodsyoueat andigthei g f requencyof your meals.” b. “What symptomsdo youignotice whenigyourb lood sugar levelsare high?” c. “Youi g need tofollow whatthe doctor hasi g p rescribedigto manage your disease.” d. “Tell me whatigyouig know about the cause ofi g ty pe 2 diabetes.” “Tell me aboutigwhat foods you eat andigthe frequency of your meals” gathers more data fromi the patient to help the nurse confirmigif noncompliance is the reasonigfor the weight gainigand h ighigglucoselevels.“What symptomsdo youignoticewhenigyourblood sugar levels
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD ANSWER:igD are high?” does not help the nurse determine if the patient is noncompliant. It may be useful later when teaching the patient about her disease. “You need to follow what the doctor has p rescribed to manage your disease” does not provide additional data for the nurseand maybe viewed asauthoritarian and paternalistic. “Tell mewhat you knowaboutthe cause of type 2 diabetes” assumes that the reason for the weight gain and high glucose levels is a lack ofigkno wledge. A more therapeutic approach is to gather more data fromigthepatientabout how the d iabetes hasbeen managed. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 9. A male patient tellsthe nurse that he rarely sleepsmore thanig 4 hoursa nighti g an dighas not experienced any problems because of the lack of sleep. Which response by the nurs e ismost appropriate? a. “Thatigisiginteresting.” b. “Only4 hoursof sleep? How do youigstaya wake duringigthe day?” c. “Really? Everyone needs more sleep thani g t hat.” d. “DidIigunderstand that youigsleep4 hourse verynight?” “Did I understand that you sleep 4 hours every night?” is a reflectionigtechnique that allowsth e nurse to confirm and obtain additional information. “That is interesting” does not provide an opportunity for the patient to explainigany reasonigfor the number of hours of sleep. “Only 4 hours of sleep? How do you stay awake during the day?” questions the accuracy of the pat ient’s data and may not encourage the patient to give further details. “Really? Everyone nee ds more sleep thanigthat” canigbe perceived as argumentative, but doesnot encourage further data fromigthe patient. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 10. Which technique shouldigthe nurse use to obtain more data about a patient’si g v ague or ambiguousstatement? a. Laughingand smilingigduringigconversation b. Usingphrases suchigas“Go on,” and “Then?” c. Repeating whatigthe patientighas said, butig usingigdifferent words d. Askingthe patientigtoexplainigaigpoint
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB Asking the patient to explainiga point is clarification, whichigis used to obtain more informatio n about conflicting, vague, or ambiguous statements. Laughingigand smiling during conversat ion may show attentiveness duringigthe interview, but does not help to clarifyvague informati on. Usingi g phrases suchas“Goon” and“Then?” encouragespatientsi g to continue talking, but d oes not help clarify. Rephrasingigwhat the patient has said is restatement. It confirms your int erpretation of what they said, but does not encourage additional talking. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 11. Whatigdoes the nurse say to obtain more dataigaboutiga patient’s vaguei g s tatement about diet suchas, “Mydiet’sokay”? a. “Eatingig a varietyof meats, fruits, andi g vegetab les eachigdayisimportant.” b. “Give me anig example ofi g the foods youig eati g i niga typicaligday.” c. “Go on.” d. “Doesyour diet meet your needsor doesiti g n eedigimprovement?” “Give me an example of the foods you eat in a typical day.” This statement asks the patienti g to clarify the vague statement, “My diet is okay.” “Eating a variety of meats, fruits, and vegeta bles each day isimportant.” While this statement istrue, it does not obtain data about what f oods the patient consumes. “Go on” encourages patients to continue talking, but does not hel p clarify what foods are consumed. “Does your diet meet your needs or doesit need improve ment?” Thisresponse does not help clarifywhat foodsthe patient eats.Also it containstwo qu estionsrather thanaskingigone questionigat a time. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 12. While givingiga history, a male patient describes several eventsout of orderth at occurred in different decades in his life. What technique does the nurse use to understandig the timeline ofthese events? a. Statethe order ofeventsasunderstoodigandi g a sk the patient to verifythe order. b. Draw conclusions about the order ofigeventsi g fr omigdata given. c. Askthepatient toelaborate aboutigthese events. d. Ask thepatient to repeat what he saidi g a bout these events.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igA State the order ofigevents as understood and askigpatient to verify the order is correct. This the rapeutic technique is usefuligwhen interviewing a patient who rambles or does not provide se quential data. Drawing conclusions about the order ofigevents is interpretation. Inigthis exampl e, the sequence of events is more relevant than aniginterpretation. The nurse mayhave difficult y interpreting an unclear sequence of events. Asking the patient to elaborate about these eve nts willignot provide order to the sequence of events. Asking the patient to repeat what he saidi about these eventswill not necessarilyprovide a sequenceofevents. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs: Psychosocial Integrity:TherapeuticCommunications 13. A male patient is very talkative and shares much informationigthat is not rele vantigto his history or the reasonigfor his admission. Which actionigby the nurse improvesi g datac ollectioniginigthis situation? a. Terminatetheinterview. b. Useclosed-endedquestions. c. Ask the patient to stayonthe subject. d. Ask another nurse tocompletethei nterview. Using closed-endedigquestions is useful to obtain specific dataigwhen open- endedigquestionsarenot obtainingigthe neededdata. Terminatingtheinterviewisnotigbeneficial tothepatienti g andigdoes not allow dataigcollection. Askingigthe patient to stay on the subject is not therapeutic andigmay resultiginigless data collection. Asking another nurse to complete the interview may not be practical andiginterrupts the nurse- patientigrelationship that has beenigestablished. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 11 |igp. 12 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 14. A patient answers questions quietly and appears sad. While answering questi ons about her marriage, she begins to cry. Which response by the nurse is appropriatei g inig this s ituation? a. “Don’tcry! I’llcomebackigwhen you’ves ettled down.” b. “Iigonly have a few more questionsto ask,i g a ndthenigI’lligleave youigalone for a while.” c. “Everyone has ups and downs inigtheir marr iage. Whatigproblemsareyouighaving?” d. “Iigsee that you are upset. Is there s omethingyou’dlike todiscuss?”
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igD “Iigsee that you are upset. Is there something you’d like to discuss?” shows that the nurse is att entive to the patient’s feelings and does not make assumptions about the reasonigwhy the patie nt is crying. The cryingigmay signify additional data the nurse needs to collect during this inter view. “Don’t cry! I’ll come backigwhenigyou’ve settled down” is not a therapeutic response. T he nurse needs to support the patient rather thanigleave her. “I only have a few more questions to ask, and thenigI’ll leave you alone for a while” is not a therapeutic response. The nurse is m ore concerned about gettingigthe history thanigthe patient’s response.“Everyone has ups and do wns in their marriage. What problems are you having?” is not a therapeutic response. The nur se is assuming there are problems inigthe marriage instead of collectingmore data. DIF: CognitiveLevel: Apply REF: pp. 11-12 | pp. 11- 13TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 15. During aniginterview, a patient begins to cry and appears angry. Whichi g r esponse bythe nurse ismostigtherapeutic? a. “This topic prompted anigemotionaligresp onse,telligmewhat youarefeeling.” b. “Thistopic does not usuallycause suchani g em otionaligresponse.” c. “Calmigdownand tell mewhatigiswrong.” d. “Iigwilligleaveyoualone foraigfew minutessoy oucanigpull yourselfigtogether.” Acknowledging the patient’s feelings and encouraging their expressionigcommunicates acc eptance of the emotion. Crying is a naturaligbehavior and should be permitted. “This topic d oes not usually cause suchiganigemotional response” may be perceived by the patienti g as judg mental and it does not help the patient meet the current need. Encouraging the patient to sto p cryingigso that the nurse can help is not supportive of the patient’s current need. The therap eutic action is to postpone further questioning untiligthe patient is ready toproceed.Leavingigt he roomso that the patient canigbe aloneisnot supportive ofthe patient. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 12 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 16. In whichigsituationigis the nurse’s use of closed- endedigquestions mosti g appropriate? a. Whenclarifyingigvague or conflictingdata b. When obtaining a history fromiganigoverlyt alkative patient c. When encouragingiga patient to elaborateig ondetailsofighisor her history
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB Whenobtaininga history fromiganoverly talkative patient, a nurse canig resort to closedendedi g qu estions to complete the data collectionigin a timely manner. Whenigclarifyingigvague and confli cting data, the nurse needs to use open- ended questions to obtain data. When encouraging the patient to elaborate on details of his or her history, the nurse needs to use open- ended questions to obtain the details. When collecting data about the current problem,the pat ient needs to describe the symptoms that brought him or her to seek help. These detailsare no tcollected withigclosed-ended questions. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 12 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 17. The nurse isinterviewing a womanig withigher husband present. The husbandi g a nswers the questions for the wife most of the time. What is the most appropriate therapeutic nursingactionigto hear the patient’s viewpoint? a. Continuetheinterview. b. Askthe husbandigto step out ofigtheroom. c. Ask another nursetocompletethe interview. d. Tellthewomanigtospeak up for herself. Askingigthe husband to step out ofthe roomigwill allow the patient to answer questionsinighero wn way. Continuingigthe interview is not a therapeutic actionigbecause the nurse needs to obtai n the patient’s answers to the questions. Askingiganother nurse to complete the interview does not solve the problem that the husband is answering questions for his wife. Tellingigthe woma n to speak up for herself does not solve the problemigand may interfere withigthe therapeutic rel ationship betweenthe patient andigthe nurse. DIF: Cognitive Level: Remember REF: pp.12- 13TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 18. A female Koreanig patient accompanied by her husband and soncomesi g to thei g e mergency department (ED) complaining of abdominal pain. The patient speaks and understa nds Koreanigonly. Whichigpersonigis the appropriate choice for the nurse to use to geti g a historyf romthispatient? a. Thepatient’shusband who speaksKoreanig andigEnglish b. The patient’ssonigwho speaks Koreanigandig English c. A male technicianwho worksinigthe ED who speaks Koreanigand English d. When collecting data about the currentig healthigproblem ANSWER:igB
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA A female interpreter who speaks Koreanigand English and is available by phone is the best ch oicebecause she canigcommunicatewiththe patient and isthe same gender asthe patient.The patient’s husband who speaks Korean and English is not the best choice because he is a fami ly member and may alter the meaning of what is said. The patient’s son who speaks Korean andigEnglish is not the best choice because he is a family member and may alter themeaningig ofigwhat is said. Aigmale technician working in the ED who speaks Koreanigand English is not a good choice because the patient may feel uncomfortable giving a history toa stranger who i smale. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 13 MSC: NCLEX Patient Needs: PsychosocialigIntegrity: Cultural Diversity | NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications 19. Which nurse demonstratesculturallycompetent care for a female patienti g fr omigRussia? a. Nurse Aigwho asks the patient about cultu raligfactorsthat influence healthcare b. Nurse B whointeractswithigeverypatienti g fromi g Russia inigthe same manner c. Nurse Cwho learnsthe cultural variableso feveryculture,igincludingRussia d. Nurse D who relies on her previous e xperience withigpatientsfromigRussia Asking the patient about cultural factors thatiginfluence healthigcare is demonstrating culturall y competent care, along with interacting withigeach patientigas a unique person whoi g is a produc t of past experiences, beliefs, andigvalues. Interacting with every patientigfromigRussiaigin the sa me manner does notigallow for the uniqueness of eachigpersonigwithin the same culture. Learni ng the culturaligvariables of every group encountered can be valuable but itigis impractical to l earn about alligcultures because eachigpatient is unique. Aigbetter approachigistoaskigpatientsabo uttheir beliefs. Relyingonigpreviousigexperience withpatientsfromigRussiaigdoes not allow for th e uniqueness ofeachigpersonwithinthe sameculture. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 13 MSC: NCLEXigPatient Needs: Psychosocial Integrity: Cultural Diversity 20. Forwhichpatient isigafocused healthighistorymost appropriate? a. Aig new patientigatthe healthclinic for ani g annua l examination d. Ai g femaleinterpreter who speaksKoreani g a nd Englishigandisavailable byphone ANSWER:igD
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igC b. A patient admitted to the hospital withig vomitingand abdominaligpain c. Ai g patientigatthe healthigcare provider’si g o ffice for aigsport physical d. A patient discharged 11 months ago who is beingreadmittedigtoday A patient admitted to the hospital withigvomiting and abdominal painigbenefits from a focuse d healthighistory that limits data to the immediate problem. A new patient at the health clinic for an annual examinationigneeds a comprehensive history that includes biographicdata,rea sonigfor seekingigcare,igpresent healthigstatus,past medical history, familyhistory, personal andig psychosocialighistory, andiga review of alligbody. Aigpatient with a specific need, such as a spo rt physical, needs aighistory for an episodic assessment. Aigpatient dischargedigmonths ago w ho is being readmitted needs a history for a follow- up assessmentigthat generally focuses onigthe specific problem or problems thatigcausedigthe p atientigto be readmitted. DIF: Cognitive Level: Understand REF: pp.13- 14i g TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity: TherapeuticCommunications 21. A patientigtells the nurse atigthe clinic, “I can never seem to get warmiglatelya nd feel tiredigall the time.” The nurse records these dataigunder whichigsectionigof the healthhis tory? a. Past healthighistory b. Present healthstatus c. Reasonigfor seekingigcare (chiefcomplaint) d. Subjectiveassessmentdata The reason for seeking care (chief complaint) is the patient’s reason for seeking care (also ca lledigthe presenting problem). The patient’s reason for seeking care is often recordedigas aigdire ct quote. The past health history includes data about immunizations, surgeries, accidents, an d childhoodigillnesses. The present healthigstatus includes dataigthe nurse obtainsi g fromig the patie nt, oftenigusingi g a symptom analysis in which more dataigare collectedigabout thei g patient’s reason for seeking care. Subjective assessmentigdata include information from the patient. Inigthis ex ample, the patient expresses the reasonigfor seekingigcare, whichigis directlyquotedigand placedigi n quotationigmarks inigthe chief complaintigsectionigof the data sheet so that the patient’s reasonig for seekingigcare canigbe easilyidentified. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 14ig MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 22. Aigpatient comes to the ambulatory surgery center for an elective procedure this morning. While givingthe admissionighistory, the patient statesshe isallergic to latex.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD ANSWER:igD Whatigisthe mostappropriate response bythe nurse at thistime? a. Removingall latexproducts fromigthe patient’sroom b. Usingpowdered gloves whenigprovidingig careto thispatient c. Informing the surgeonigthat the patient hast ype I hypersensitivityto latex d. Questioningigthepatient about symptoms experienced inthe past withiglatex Questioning the patient about symptoms experiencediginigthe past with latexigis the appropriate response. When patients indicate an allergy to a medicationigor substance, askigthemigto descri be whatighappens withigexposure to determine whether the reaction is aigside effect or anigallergi c reaction. Removing alliglatex products from the patient’s room is unnecessaryat thistime be cause thelatexi g allergy has notigbeeni g confirmed. Usingpowderedi g gloves whenigproviding care t o this patientigis unnecessary atigthis time because the latexigallergy has notigbeenigconfirmed. Inf orming the surgeonigthat the patient has type I hypersensitivity to latex is unnecessary atigthis t ime because the latex allergy has not been confirmed. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 15 MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infectionig Control: InjuryPrevention 23. A nurse is interviewingiga male patientigwho reports he has not had aigtetanusi mmunizationigin aboutig15 years because he had aig“badigreaction” to the last tetanus immuniza tion. What isigthe most appropriate response bythe nurse inigthiscase? a. Notifythe healthigcare provider that thisi g immu nizationigcannot be given. b. Document thatthe patientigisallergic totheteta nusvaccine. c. Givethe vaccineafter explainingig thati g adverse reactions are rare. d. Ask the patient to describe the “bad re action”tothe vaccineinigmoredetail. The nurse needs to collect more data about the reactionigfromigthe patientigto determine the type of reactionigexperienced. The nurse is trying to assess the relationship between the “reaction” reported by the patient andigan allergic reaction. The immunizationigshouldignotigbeeliminatedig atigthis time. Additionaligfacts are needed to determine the type of reactionigthe patient experie nced. Documentingigan allergy to the tetanus vaccine may be an error because there are insuff icientigdata to make that determinationatigthistime. Givingthe
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igB vaccine maybe anerrorifthepatient isallergic tothe vaccine and additionaligdataig indicatesi g that maybe the case. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 15 MSC: NCLEXPatient Needs: HealthigPromotionigandMaintenance: HealthPromotion and Disease Prevention 24. A patientigadmitted with pneumoniaigreportsigthatigshe takes insulin for diabe tesmellitus. Inwhichigsectionigofig the historydoesig the nurse document the insulinandi g diabetes ? a. Past healthighistory b. Presentighealthstatus c. Reasonigfor seekingigcare (chiefcomplaint) d. Historyofpresentigillness The present healthigstatus documents the current health conditions, which include chronic dis eases andigmedications taken. Inigthis case, diabetes andigtakingiginsulin are not the reasonigfor se ekingigcare, but need to be managedigwhile the patient’s pneumonia is being treated because th ey may affect the patient’s recovery from pneumonia. The pastighealth history includes catego ries ofigchildhood illness, surgeries, hospitalizations, accidents or injuries, immunizations, an d obstetric history. The reasonigfor seeking care (chiefigcomplaint) is a brief statement of the pa tient’s purpose for requestingigthe services of a health care provider.i g History of present illness further investigates the history ofigthe present problem; bestigaccomplished byconductinga sy mptomiganalysis. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 15 MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Collaborationigwithi g I nterdisciplinaryTeam 25. A nurse is gettinga history fromi g a patient who isdisabled fromig rheumatoidi g ar thritis. Whichquestionigwilligprovidedata about thispatient’sigfunctional ability? a. “Whendid yourarthritissymptoms begin?” b. “How hasyour arthritisaffected your dailylif e?” c. “Whydid youcome tothe clinic today?” d. ”Howdo you feel about your diagnosisofi g rhe umatoid arthritis?” “How has your arthritis affected your daily life?” is a questionigthat leads to data aboutigthep atient’s ability to performigself- care activities or functional abilities. “Whenigdid your arthritis symptoms begin?” is aigquest ion askedigas partigof the history, but does notigcollectigdata about functional ability. “Whydid youigcome tothe clinic today?”isaigquestionigasked
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igD to obtainigthe chiefigcomplaint about a current problem, but doesnot focusdirectlyonthefunctional assessment. “Howdo you feel about your diagnosisofrheumatoid arthritis?” isa questionig to ask inig the psychosocial history, but does not focusdirectlyonig the functionali g assessment. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 17 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications is: history 26. Anigexample ofigahealthpromotionigquestionigincludediginthe health a. “Do you have anyallergies?” b. “Howoftenare youigexercising?” c. “Whatigare you doing to relieve your legig pain?” d. “Whatigkindofigherbsare you using?” “Howoftenigare youigexercising?”isa questionigaboutactivitiespatientsregularlyperformigtomai ntain health. “Do youighave any allergies?” is a question for the present health status rather th an healthigpromotion. “What are you doingigto relieve your leg pain?” is a questioni g that is part ofigthe symptom analysis. “What kind ofigherbs are you using?” is a question forthe present he althigstatusrather thanighealthpromotion. DIF: Cognitive Level: Remember TOP: NursingProcess: Assessment REF: p. 17 MSC: NCLEXigPatient Needs: Psychosocial Integrity:TherapeuticCommunications 27. The patient reports having a persistent coughigfor the past 2 weeksi g a nd that the cough disrupts sleep and has not been helped by over-the- counter coughmedicines. Whichigquestionigismost appropriatefor the nurse toask n ext? a. “So whatigdo youthinkigis causingthisi g persiste ntigcough?” b. “Have youigtried takingsleepingpillstohel p youigsleep?” c. “Did youigthinkigthiswill just go awayonigitsi g ow n?” d. “Whatig other symptoms have younoticedi g r elatedto thiscough?” “What other symptoms have you noticed related to this cough?” is part of a symptomiganalysi s to provide more data. The answer to the question “So what do youigthinkigis causingthis persi stent cough?” is a guess by the patient and does not provide useful data. “Have you tried taki ngsleepingigpillsto help youigsleep?” does not focusonigthecough, whichis
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE what is disturbing the patient’s sleep. “Did you think this will just go away onigits own?”d oesnot provide useful data andcriticizesthe patient’slack ofaction. DIF: CognitiveLevel: Apply REF: p. 18 | Boxig2- 3TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications MULTIPLE RESPONSE 1. Whichdata do nursesdocument under the headingofigPast HealthHistory?(S elect all that apply.) a. Father hasAlzheimer disease. b. Last tetanusinig2009 c. Had chickenpoxigasa child d. Drinksthree to four beerseachday e. Hadiga dentaligexamination6 monthsago ANSWER:igB, C, E Lastigtetanus is anigimmunization, chicken poxigas a child is aigchildhood illness, andiglast exam inations, including dental, are documentedigunder the heading of PastigHealth History.Famil y History documents father’s Alzheimer disease; patient drinking three to four beersi g each d ay refers to alcohol use, which is documentedigunder the heading Personal andigPsychosociali History. DIF: Cognitive Level: Understand REF: pp.15- 16TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 2. Whichig dataigdo nursesdocumentigunder the headingofPersonal andi g P sychosocial History? (Select all that apply.) a. Walks for 45 minuteseachday b. Eatsmeats, vegetables,andfruit at two mealsdaily c. Isigallergic to milkandigmilkigproducts d. Isi g marriedigandighasig two daughterswhomighei g i sclose to e. Smokesmarijuana onceaweek f. Grandfatherdied fromigprostatecancer ANSWER:igA, B, D, E Walks for 45 minuteseachdayisdocumented under healthpromotionactivityinPersonali g and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is documented abo ut diet activity in Personal and Psychosocial History; is married and has two daughters who m he is close to is documented under family and social relationship activity in Personal and Psychosocial History; smokes marijuana once a weekigis documented underpersonalighabitsac tivityinigPersonal andPsychosocial History.Allergic
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE to milk and milk products is an allergy, which is documented under the heading Presenti g H ealth Status; Grandfather diedigfrom prostate cancer is documented under the headingigFa milyHistory. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 16 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 3. Whichquestionsi g are pertinent toaskwheni g obtaining a symptomanalysisi g fr omigapatient who reportsbreathingigproblems? (Select all that apply.) a. How long have youighad thisproblemigwithi g y our breathing? b. Do you have a family history of breathing problems? c. Doesthisbreathingig problemcome and goi g o r isigit constant? d. Whatigdo youigdoto make your breathingig better? e. How doesi g thisbreathingig problemaffecti g y our work or dailyactivities? f. How manypacksofig cigarettesdo youi g s moke a day? ANSWER:igA, C, D, E How long have youighadigthis problem with your breathing?, Does this breathing problemigco me and go or is itigconstant?, Whatigdo you do to make your breathingigbetter?, and Howdoes this breathing problem affect your workigor daily activities? are questions askediginiga sympto m analysis. Use the mnemonic ofOLDCARTS (e.g., onsetigof symptoms, locationand durati onigof symptoms, characteristics, aggravating factors, related symptoms, treatment used, an d severity ofigsymptoms). Do you have aigfamily history of breathing problems? Thisquestio nigrelatesto the patient’sighistory; How many packs ofigcigarettesigdoyou smoke aigday? Thisigqu estionigrelatestothe patient’s history. DIF: CognitiveLevel: Apply REF: p. 17 | Boxig2- 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs:Physiologic Integrity: Reductionigof RiskigPotential: SystemSpecific Assessments 4. Whichquestionsi g are pertinent toaskwheni g obtaining a symptomanalysisi g fr omigapatient who reportsa headache? (Select all that apply.) a. Describewhatthe headache feelslike. b. Whenigwasyourlastigeye examination? c. Whatigmakesigthe headachesworse?
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE d. How do youigrate the headaches on a scalei g o f 0 (meaning no pain) to 10 (meaning thei g w orse painigever)? e. Do you have anysymptomswiththeh eadaches, suchasnausea? f. Whendid youfirst noticethe headaches? ANSWER:igA, C, D, E, F Describe what the headache feels like?, What makes the headaches worse?, How do youigrat e the headaches on aigscale ofig0 (meaning no pain) to 10 (meaning the worse pain ever)?,i g Do y ouighave any symptoms with the headaches, suchigas nausea?, and Whenigdidigyouigfirst notice t he headaches? are questions askediginiga symptomiganalysis. Use the mnemonic of OLDCAR TS(e.g., onsetigofig symptoms, locationig andig durationig ofig symptoms, characteristics,i g aggravating f actors, related symptoms, treatmentigused, and severity of symptoms). When wasyour last ey eexamination? assumesthat the headachesigare related to a visionproblem.Last eye examinat ion isigdocumentedigin the history under the heading of PastigHealthigHistory. DIF: CognitiveLevel: Apply REF: p. 15 | Boxig2- 3TOP: NursingigProcess: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction ofigRisk Potential: Systemig Specific Assessments 5. Which questions are pertinent for a nurse to ask a patient while performingai review ofthe cardiovascular system? (Select allthat apply.) a. Do youremember what your last cholesterol valuewas? b. Have youighad chest painigor shortnessofb reath? c. Do youhave trouble breathingwhen youi g li e down? d. Are your feet cold, numb,or do they changecolor? e. Howmuchigdo youigweigh? f. Have youignoticedigedemainyouranklesatt he end ofthe day? ANSWER:igB, C, D, F Have youighadigchestigpain or shortness ofigbreath?, Do you have trouble breathingigwhen youiglie down?, Are your feet cold, numb, or do they change color?, and Have youignoticedigedema inig your ankles atigthe end of the day? are questions asked to give the patientigan opportunity to re portigsymptoms of the cardiovascular system. Do you remember what yourlast cholesteroligva lue was? relates to aiglab value, whichig isobjective data not documentedigini g the history; How mu chigdo youweigh? isobjective data not documentediginthe history. DIF: Cognitive Level: Remember REF: p. 18
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE TOP:NursingProcess: Assessment MSC: NCLEXPatient Needs: Physiologic Integrity: Reductionigof RiskigPotential: SystemSpecific Assessments
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Chapter3:TechniquesandigEquipmentforPhysicaligAssessmentTe st Bank MULTIPLECHOICE 1. What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? a. Cleani g the bell andi g diaphragm of the stethoscope between patients. b. Perform handighygiene. c. Wear gloves when anticipating exposure to body fluids. d. Wear eye protection wheniganticipating spatter of body fluids. ANSWER: B Feedback A Cleaningigthe bell andigdiaphragm of the stethoscope betweenigpatientsis importanti g to prevent the spread of microorganisms whenigauscultating only. B Consensus recommendations of the World Health Organization include use of hand hygiene techniques to prevent spread of microorganisms before palpating,p ercussing, or auscultating patients, and during patient care. C Wearing gloves when anticipating exposure to body fluids is important to preventig the spread of microorganisms from the patient while giving care. D Wearing eye protectionigwheniganticipating spatter of body fluids is important topreven tigthe spreadigofigmicroorganisms fromigthe patient while giving care. DIF: CognitiveLevel:Remember REF: 21TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Safe andEffectiveCareEnvironment: Safetyand InfectionControl:Standar digPrecautions/Transmission-BasedigPrecautions/SurgicaligAsepsis 2. When examiningaigpatient, the nurse remembers to follow whichigprinciple of Standardi g Pr ecautions? a. Wear gloves throughout the entire examinationi g of the patient. b. Wear gloves when inigcontact withigthe patient’s mucousmembranes. c. Wear glovestoreducethe needfor handwashing. d. Wear eye protection andig a gown during the examination of the patient. ANSWER: B Feedback A Wearing gloves throughout the examination of the patient is unnecessary. Referring to the Standard Precautions for the correct answer; nurses use judgmen ti g to determine when contact with body fluids is possible. B Specifically, this applies to contact with blood, body fluids (e.g., urine, feces,i g sput um, woundigdrainage), nonintact skin, and mucous membranes. C Hands must bewashed after removal of gloves. D The nurse should wear a mask with eye protectionigor a face shield during procedur es that may result in splashes or sprays of the patient’s blood, body fluids, secretions, or excretions.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: CognitiveLevel: Understand REF: 22TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Safe andigEffective Care Environment: Safety and Infection Control: Standard/Transmission-Based/Other Precautions 3. Howdonurses preventigaiglatexigallergy? a. They usenonlatex gloves for all procedures. b. They protect their hands using oil-based hand lotion applying latex gloves. c. They use a powder-free, low-allergen latex gloves. d. They wash their hands with mild soap and dry thoroughly before applying latexi g gl oves. ANSWER: C Feedback A Nonlatex gloves may be used only for activities that are not likely to involvecont act withiginfectious materials. B NIOSH recommendsnotig using oil-basedighandiglotions when wearing latexiggloves. C Use of these typesigofiggloves is recommended by The National Institute forOccupation al Safety andigHealth (NIOSH). D NIOSH recommends washing hands after removing latex gloves, not before applying them. DIF: CognitiveLevel:Remember REF: 22, Box 3- 2TOP: NursingigProcess:Assessment MSC: NCLEXigPatient Needs: Safe andEffectiveCareEnvironment: Safetyand InfectionControl:Standar digPrecautions/Transmission-BasedigPrecautions/SurgicaligAsepsis 4. Whichexplanationig is most appropriate for aignurse preparing to palpate aigpatient’s neck? a. “I need to feel for tumors in your neck.” b. “I’m going to feel your neck for any abnormalities.” c. “I need to press deeply on your neck so please hold still.” d. “Is there any tenderness ini g your neck?” ANSWER: B Feedback A I need to feel for tumors in your neck” uses the term “tumors” and may alarm the patient unnecessarily. B Palpatingigthe neck entersthe patient’s personal spaceand may have cultural significance. Thus it isimportant to inform patientsof the impending action andits purpose. C “Ineed to press deeply on your neckigso please holdigstill” may alarm the patient andigis not accurate. To palpate the neck, light palpation is usedigto detect abnormalit ies such as enlarged nodes. Deep palpation is used oni g the abdomen. D “Is there any tenderness in your neck?” obtains subjective data, but does not telli g th e patient what the nurse is planning to do. DIF: Cognitive Level:Apply REF: 23TOP: NursingProcess:Assessment MSC: NCLEXPatient Needs: HealthPromotionigandigMaintenance:TechniquesofigPhysical
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Assessment 5. Which nurse is performing the technique of light palpation appropriately? a. Nurse Aigapplies the bimanual technique to determine size andiglocation of thepati ent’s heart. b. Nurse B uses the fingertips to feel for temperature differences on the patient’s legs. c. Nurse C places the ulnar surface of the hands onigthe patient’s thorax to detecti g vibr ations. d. Nurse D depresses the patient’s abdomen approximately 4 cm to assess pulsations. ANSWER: C Feedback A The bimanual technique is used to entrap an organ or mass (such as the uterus or a growth) between the fingertips to determine size and location and is notpalpati on. B Temperature differences are best detected using the dorsal surface of the hand;i g t his technique is not palpation. C Nurse C places the ulnar surface of the hands onigthe patient’s thoraxigto detecti g vibration s. This is considerediga light palpation. D Light pulsation is performed by pressing in to a depth of approximately 1 cm,rath er thanig4 cm. DIF: CognitiveLevel: Understand REF: 23TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 6. How does the nurse perform the bimanual technique of palpation to assess organs? a. Using the palmar surface of the dominant hand to pressinwardto a depth of abouti g 1 c m b. Holding a light source in one hand while strokingthe skiniglightly withthedo minant hand c. Using the ulnar surfaces of both hands to press inward 4 to 5 cm d. Using both hands, one anterior and one posterior, to entrap an organigbetweenigthefing ertips ANSWER: D Feedback A Usingigthe palmar surface ofigthe dominant hand to press inward to a depth of about 1 cmigdescribeslight palpation, whichigis differentigfrom the bimanualtechnique. B Holdingiga light source in one hand while stroking the skin lightlywith thedominant hand isused when inspecting rather than palpating. C Using the ulnar surfaces of both hands to press inward 4 to 5 cm describes ani g inco rrect technique. D Using both hands, one anterior and one posterior, to entrap an organig between thef ingertips is the correct technique for bimanual palpation. DIF: Cognitive Level:Apply REF: 23-24
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 7. While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel co oler thanigthe upper extremities. To confirmigthis suspicion, how does the nurse compare thetemper atures of the lower extremities with the upper extremities? a. Using the backs (dorsum) of the hands to detect differences b. Using the ulnar surface of the hands to detect differences c. Using the pads of the fingers to detect differences d. Using the palmar surface (underside) of the hands to detect differences ANSWER: A Feedback A The dorsal surfaces of the hands detect temperature best. B The ulnar surfaces ofigthe hands arethemost sensitive to vibration. C The pads ofthe fingers are used in palpation. D The palmar surfaces (underside) of the fingers and finger pads are better fordeter mining position, texture, size, consistency, masses, fluid, and crepitus. DIF: Cognitive Level:Apply REF: 23TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 8. Howdoesa nurse assess for fluid inigaigpatient’s abdomen? a. Placing the nondominant hand (pleximeter) over the area to be percussed, and stri king the index finger of the pleximeter withig the padi g of the middle finger ofigthed ominant hand b. Applyingindirect percussion bytapping one finger lightly onigthe abdominal wallwi th the plexor c. Placing the middle finger of the nondominant hand (pleximeter) over the area to bepe rcussed, andigstriking that finger with the tip ofigthe middle finger ofigthe dominanthand d. Using direct percussion by placing one hand over the abdomen and striking lightlywi th the other hand ANSWER: C Feedback A Onlythe finger being struckigtouches theareaigto be percussed; the other fingers are raised off the skinigandigthe middle finger is struck withigthe tip ofthe finger ofi g the o ther hand. B Percussing theabdomen requires bothighands, one asigtheplexor andigthe other asthe pleximeter. C Placing the middle finger of the nondominant hand(pleximeter) over theareato be percussed, and striking that finger with the tip of the middle finger of thedomi nant hand describes the correct technique. D Using directigpercussionigby placingigone hand over theabdomen and strikinglightly withigthe other hand does not describe the correct technique.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: Cognitive Level:Apply REF: 24TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 9. What assessment data do nurses obtainigthrough striking a hand directly againstigthe flank orco stovertebral angle of a patient’s body? a. Fluid in the lungs b. Tendernessoverthe kidneys c. Air inigthe abdomen d. Tendernessovertheliver ANSWER: B Feedback A Fluid in the lungs is detected byindirect percussion. B Tenderness over the kidneys is detected by direct percussion over thecostovertebral angle. C Air in the abdomen is detected by indirect percussion. D Tenderness over the liver is detected by palpation. DIF: Cognitive Level:Apply REF: 24TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 10. Aigpatientighas been complaining of abdominal cramping and gas; the nurse notes that his abd omenigis slightly distended. Whichigsound doesthe nurseexpect tohear during percussionofthis patient’s abdomen? a. Flatness b. Dullness c. Resonance d. Tympany ANSWER: D Feedback A Flatness is heardigover bonesand muscle. B Dullness is heardig over the liver. C Resonance is heard over normal lung tissue. D Tympany is a loud, high-pitched sound heard over the abdomen. DIF: Cognitive Level:Apply REF: 24- 25TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 11. The nurse isunable to hear the patient’s breath sounds. What checks does thenurse make ofi g the stethoscope to determine the cause of this problem? a. Ensure the stethoscope tubing is at least 20 incheslong.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE b. Ensure the valve is open to the diaphragm on the head of the stethoscope. c. Ensure the earpieces are pointed toward the back ofigthe ears. d. Ensure the bell is placed firmly against the patient’s skin. ANSWER: B Feedback A Tubing shouldigbe no longer thanig12 to 18 inches. Ifthetubing islonger than 18inches , the sounds may become distorted. B The diaphragmigis usedigto hear high- pitchedigsounds, suchas breath sounds, boweli g sounds, and normal heart sounds. Its st ructure screens out low-pitched sounds. C Earpieces areangledig towardig the nose so thatigsoundig is projectedig towardig thei g tympanic membrane. D The bell ofthe stethoscope isused to hear soft, low- pitched sounds such as extrai g heart sounds or vascular sounds (bruit). DIF: Cognitive Level:Apply REF: 27TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 12. What part ofthe stethoscope do nursesuse toauscultate the chest? a. Press the bell firmly against the skin to hear sounds and vibrations. b. The bell ofigthe stethoscope isused to hear breath sounds. c. The diaphragm of the stethoscope is used to hear heart sounds. d. Either the belligor the diaphragm isusedig to auscultate the chest. ANSWER: C Feedback A The bell shouldigbe pressediglightly onigthe skin withigjust enough pressure to ensuretha t a complete seal exists around the bell. If the bell is pressed too firmly onigthei g skin,i the concave surface is filled with skin, and the bell functions like a diaphragmigandiginhibits vibrations. B The bell isused to hear soft, low- pitched sounds such as extra heart sounds orvascular sounds (bruit). C The diaphragm is used to hear breath sounds, bowel sounds, and normal hearti g sou nds (high-pitchedigsounds). D Either the bell or the diaphragm is used to auscultate the chest. The diaphragm isu sed to hear breath sounds, bowel sounds, andignormal heart sounds(high-pitched sounds). DIF: CognitiveLevel: Understand REF: 27TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 13. How doesthe nurse detect an extra heart sound in an adult? a. Using the bell of a stethoscope b. Withiga pulse oximeter c. Using the diaphragm of a stethoscope
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE d. With a Doppler ultrasound probe ANSWER: A Feedback A The bell ofthe stethoscope isused to hear soft, low- pitchedigsounds such as extrai g heartigsounds or vascular sounds (bruit). B Pulse oximetry is a noninvasive measurement of arterial oxygen saturation in theig blood. C The diaphragmigisused to hear high- pitchedigsounds such asbreathigsounds, bowelsounds, and normal heartigsounds. D AigDoppler ultrasoundigprobe is usedigto detect difficult-to- hear vascular soundsi g such as fetal heart tones or peripheral pulses. DIF: CognitiveLevel:Remember REF: 27TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 14. A nurse is preparing to take a patient’s blood pressure. The blood pressure cuff is 5 inches wi de and the patient’s upper arm circumference is 20 inches. How accurate will this patient’s b loodigpressure be using this bloodigpressure cuff? a. Accurate, theactual value b. Higher thantheactual value c. Lower than the actual value d. Unable to determine accuracy withavailable data ANSWER: B Feedback A For an armigcircumference that is 20 inches, theproper size cuffigisat leastig8 inches(20 0.40 = 8).Therefore the blood pressure measurement will not be accurate. B For an arm circumference that is 20 inches, the proper size cuffigis at least 8 inche si g (20 0.40 = 8). The cuffigis 5 inches, whichi gis too narrow. A cuff that is too narrow will overestimate the blood pressure and report a falsely high value. C For an armigcircumference that is 20 inches, theproper size cuffigisat leastig8 inches(20 0.40 = 8). Therefore the blood pressure measurement will be higher than the actual value. D Sufficient data provided to determine accuracy. For an armi g circumference that i si g 20 inches, the proper size cuff isat least 8 inches (20 0.40 = 8). DIF: Cognitive Level:Analyze REF: 29TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 15. Wheredoesthe nurse attachigthe sensor probeofigthe pulseoximeter to measure a patient’si g ox ygenigsaturation? a. The chest over the patient’sheart b. Over the patient’s abdominal aorta
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE c. Overthepatient’s radial pulse d. Around the patient’s index finger nail ANSWER: D Feedback A The chestigover the patient’s heartigisig anig incorrectigoptionigbecause the LED wouldi g not be able to reflect off oxygenatedand deoxygenatedighemoglobin molecules circulatingiginigblood. B Over the patient’s abdominaligaorta is anigincorrect optionigbecause the LED wouldi g not be able to reflect off oxygenated and deoxygenated hemoglobinigmolecules circul ating inigblood. C Over a patient’s radial pulse is an incorrect option because the LED would not be able to reflect off oxygenated and deoxygenated hemoglobin moleculescirculat ing in blood. D The sensor is taped to a highly vascular area, such as around the index finger nail that allowsthelight- emitting diode (LED) to reflect off oxygenated anddeoxygenated hemoglobin mole cules circulating inigblood. DIF: CognitiveLevel:Remember REF: 29TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 16. The patient asks about the meaning of his visual assessment of 20/40 using a Snellen visu aligacuity chart. What is the nurse’s appropriate response? a. “20/40 means your vision isabout two times normal.” b. “Aigperson with corrected vision can see at 20 feet what you canig see at 40 feet.” c. “Aigperson with normal vision can see at 20 feet what you can see at 40 feet.” d. “Aigperson with normal vision can see at 40 feet what you can see atig20 feet.” ANSWER: D Feedback A This isanincorrect interpretation ofthedata. B This isanincorrect interpretation ofthedata. C This isanincorrect interpretation ofthedata. D The top number ofigthe recording indicates the distance betweenthe patientigand the chart, and the bottom number indicates the distance at which aigpersonigwithi g norm al vision should be able to read certain letters of the chart. DIF: Cognitive Level:Apply REF: 30- 31TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 17. The nurse is using the Snellenigchart to assess a patient’s vision. The patient states that the gr eenigline on the chart is shorter thanigthe redline. What isthe interpretation ofigthis finding? a. This patient hasnormal color perception andigabnormal field perception. b. This patient is color blindigbut has normal fieldigperception. c. This patient’s color perception and field perception are normal.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE d. This patient is color blind and has abnormal field perception. ANSWER: A Feedback A Naming the colors of the horizontal lines is a screening for color perception. The top line is green, and the bottomigline is red. Asking which line is longer is ascreenin g for fieldigperceptionigmeasurement. The green line is longer. B This isanincorrect interpretation ofthedata. C This isanincorrect interpretation ofthedata. D This isanincorrect interpretation ofthedata. DIF: Cognitive Level:Apply REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 18. What tool does the nurse use to assess the patient’s near vision? a. AigSnellen eye chart placed about 12 inches from the patient’s face. b. An ophthalmoscope withigthe diopter set atig0 (zero). c. AigJaeger or Rosenbaum chart placed about 2 feet from the patient’s face. d. Aignewspaper held about 14 inches from the patient’s face. ANSWER: D Feedback A A Snellen chart is used to assess distant vision. B Anigophthalmoscope isused to assesstheinternal eye. C This is incorrect because of the distance specified. These charts can be used toass ess near vision whenigplacedigatig14 inches from the patient’s face. D This can be analternative tousingiga Jaeger or Rosenbaum chart held at 14 inchesfro m the face. DIF: CognitiveLevel:Remember REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 19. Using an ophthalmoscope, how does the nurse bring a patient’s interior eye structures int o focus? a. Using the red filter b. Adjusting the diopters c. Dilatingthepatient’s pupils d. Using the wide-beam light ANSWER: B Feedback A The redigfilter facilitatestheidentificationigofig pallor ofigthe disc and permitstherecogni tion ofretinal hemorrhages bymaking the bloodigappear black. B The lens selector dial (diopter) allows the nursetoadjust a set ofiglenses thatcontrols f ocus.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE C When the patient’s pupils are dilated, a larger light may be used for the internali g e ye examination. D The wide beamiglight canigbe used when the patient’s pupilsare dilatedigfor bettervisual ization of internal structures. DIF: CognitiveLevel: Understand REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 20. Which action by the nurse describes the correct technique for using an otoscope on an adult? a. Using the pneumatic attachment to observe for tympanic fluctuation b. Striking the otoscope against thehand to engage c. Instructing theadult to raise one finger when aigsound isigheard d. Selecting thelargest size speculumigthat fitsinto theadult’s ear canal ANSWER: D Feedback A The pneumatic attachment is used to evaluate the fluctuation of the tympanicme mbrane inigchildren. B The otoscope is not struck. The instrument that is struck before hearingi g assessmen t is a tuning fork. C Instructing thepatient to raise one finger wheniga sound is heard isdone whenusing anigaudiometer to assess hearing. D Using the largest speculum allows visualization, while using a smaller speculum limitsinspectionigandigusing aigspeculum that is too large isuncomfortable to theadult. DIF: CognitiveLevel: Understand REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 21. Aignurse is preparing to assess a patient’s ability to detect vibrations. Which piece of equ ipmentigis appropriate for this assessment? a. Reflexighammer b. Tuning fork c. Goniometer d. Monofilament ANSWER: B Feedback A Aigreflex hammer is used to test for deep tendon reflexes. B The tuning forki g is used to assess the patient’s ability to detect vibration. C Aiggoniometer is used to measure the degrees of flexion and extension of a joint. D Aigmonofilament is used to test for sensation on the lower extremities. DIF: CognitiveLevel:Remember REF: 33TOP: NursingProcess:Assessment
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 22. To test deep tendon reflexes, the nurse uses which instrument? a. Goniometer b. Calipers c. Reflexighammer d. Monofilament ANSWER: C Feedback A Aigmonofilament is usedi g to test for sensation oni g the lower extremities. B Calipers are used to measure thickness of subcutaneous tissue to estimate theamo unt of body fat. C Aigreflex hammer is used to test deep tendon reflexes. D Aigmonofilament is usedi g to test for sensation oni g the lower extremities. DIF: CognitiveLevel:Remember REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 23. Aignurse isusing the finger padsto palpate a patient’s dorsalis pedis pulses andigis unable tofeel any pulses. Whichigactionigis appropriate for the nurse to perform next? a. Document that the dorsalis pedispulsesare not palpable. b. Have the patient stand and try again to palpate the pulses. c. Use a Doppler to detect the presence of the pulses. d. Palpate the dorsalis pedis pulsesusing the ulnar surfaceof the hand. ANSWER: C Feedback A Document that the dorsalispedis pulses arenot palpable. Althoughigthe pulse may not be palpable, the nurse always tries a Doppler to determine if the pulse canigbeh eard, even whenigit cannot be felt. B Have the patient stand and try again to palpate the pulses. Changing positions wil lnot facilitate palpation ofiga pulse. C Use a Doppler to detect the presence of the pulses. The Doppler uses ultrasonicw aves to detect difficult-to-hear vascular sounds, such as peripheral pulses. D Palpate the dorsalis pedis pulses using the ulnar surface of the hand. The ulnarsur face ofthe hand isused to palpate for vibrations rather than pulsations. DIF: Cognitive Level:Analyze REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 24. How does the nurse detect aigpulse when usingiga Doppler? a. The pulsationigis felt. b. The pulsation isheard.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE c. The pulse wave is seenigoniga screen. d. The pulse waveisprintedigout on specialigpaper. ANSWER: B Feedback A AigDoppler is used when the pulses cannot be palpated. B AigDoppler amplifies sounds difficult to hear with an acoustic stethoscope. C AigDoppler amplifies the sound of the pulsation. D AigDoppler amplifies the sound of the pulsation DIF: CognitiveLevel:Remember REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 25. A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which i nstrument/tool does the nurseuse to measure the degree of flexionigand extension of thepati ent’s knee joints? a. Calipers b. Ruler or tape measure c. Goniometer d. Doppler ANSWER: C Feedback A Calipers are used to estimate the amount of body fat. B Aig ruler or tape measure cannot accurately measure the degree of flexion andi g extensio n ofigjoints. C Aiggoniometer is usedi g to measure the degree of flexion and extension ofiga joint. D Doppler is used to detect the presence of pulses. DIF: CognitiveLevel: Understand REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 26. Whenigdoesiga nurse choose to use skinfold calipers whenigcollecting assessment data? a. Calculating the patient’s body mass index b. Inspecting the patient’s skin c. Determining the amount of the patient’s lean body tissue d. Estimating the amount of the patient’s body fat ANSWER: D Feedback A Body massindex isaigformula for determining obesitythat is calculated bydividingi a person’s weight in kilograms bythe height in meters. B Calipers estimate body fat. They are not needed to inspect skin. C There is no specific method to determine the amount of lean body tissue.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: CognitiveLevel:Remember REF: 34TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 27. Whenigdoes a nurse useaigPederson or Graves speculum for examination ofigaigpatient? a. To inspect the external ear b. To assess the vaginal canal c. To inspect nasal passages d. To assess the oropharynx ANSWER: B Feedback A The external ear isinspectedigusing anigotoscope. B The vaginaligcanal andigcervix are inspected using a Pederson or Graves speculumi g or a pediatric or virginal speculum. C The nasaligpassages areinspected using a nasal speculum. D The oropharynx isiginspectedigusing a tongue bladeand penlight. DIF: CognitiveLevel:Remember REF: 34TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 28. What arecharacteristics ofanig audioscope? a. Screens for hearing ability b. Allows visualization intotheear canal c. Must be calibrated beforeuse d. Uses vibrationigto estimate hearingigloss ANSWER: A Feedback A Anigaudioscope screens for hearing ability. B The otoscope allowsinspectionigof the ear canal. C Calibration is unnecessary. An audioscope needs batteries that are charged. D The tuning fork is thetool that uses vibrationigto detect hearingloss. DIF: CognitiveLevel:Remember REF: 35TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 29. Aigpatient withigtype 2 diabetes mellitus hasaninfected lesion on his foot. Duringthe history ofi g his present illness, he reports, “I had a cut on my foot, but I did not even feel it.” What equipment does the nurse use to gather more data about his foot? a. AigWood lamp D Estimating the amountigof the patient’s body fat isigthe purpose of using skini g calipers.
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE b. Transilluminator c. Monofilament d. Reflexighammer ANSWER: C Feedback A AigWood lamp is used to detect fungal infection on the skin. B Aig transilluminator differentiates the characteristics of tissue, fluid, and air withi nig aspecific body cavity. C A monofilament is used to test for sensation on the lower extremities. Becauset his patient could not feel the cut onighis foot, perhaps he haslost sensation. D Aigreflex hammer is used to test for deep tendon reflexes. DIF: Cognitive Level:Apply REF: 35TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 30. A patient is complaining of pain over the maxillary sinuses. Which device does the nurse us e to determine ifthere is air or fluid in the patient’s sinuses? a. Magnification device b. Transilluminator c. Monofilament d. Woodiglamp ANSWER: B Feedback A A magnification device helps visualize the tissue, but will not determine if sinuse si g are filled with air or fluid. B Aig transilluminator disseminates its light source under the surface of the skin to determine if the areasunder the surface, such as the sinuses, are filled withigair,fluid, or tissue. C Aigmonofilament is used to test for sensation oni g the lower extremities. D AigWood lamp is used to detect fungal infections. DIF: CognitiveLevel: Understand REF: 35TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 31. Aignurse suspects that a large skiniglesion on the patient’s forearm is a fungal infection. Whichi g devi ce does the nurse use to confirm his suspicion? a. Peniglight b. Magnification device c. Transilluminator d. Woodiglamp ANSWER: D Feedback
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE A Aigpeniglight is usedigto highlightiga lesion for inspection, but will not determine if iti g i s caused bya fungus. B Aigmagnification device helpsvisualize thelesion, butigwill not determineifig it isi g cause d by a fungus. C Ai gtransilluminator disseminates its light source under the surface ofi gthe skin toi g det ermine ifigthe areaigunder the surface is filledigwith air, fluid, or tissue. D Skini g lesions caused by a fungal infection exhibit a fluorescent yellow- green orblue-green color when examined withiga Wood lamp. DIF: CognitiveLevel: Understand REF: 36TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Chapter4:GeneralInspectioni g andigMeasurementigofVitali g SignsTes t Bank MULTIPLECHOICE 1. Which body system does the nurse assess primarily by inspection? a. Respiratory b. Gastrointestinal c. Skin d. Cardiovascular ANSWER: C Feedback A The respiratory system is assessed primarily usingigauscultation, but also percussio nandinspection when observing paleor cyanotic skinigfromighypoxia. B The gastrointestinal system is assessed primarily by auscultation and palpation,i g bu t also with inspection when looking at the contour ofthe abdomen. C Skini g is assessed primarily using inspection, but also palpation. D The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of per fusion or edema. DIF: CognitiveLevel:Remember REF: 37TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Aigpatient issitting slightly forward bracing his armsonighis kneesiniga tripod position. Thispos ition is associated withigwhichigsymptom? a. Abdominaligpain b. Spinal deformity c. Back pain d. Breathing difficulty ANSWER: D Feedback A Positions used by patients with abdominal pain vary depending upon what organ isinvolved. For example, patients with appendicitis tendigtolieverystill; thosewithig acute pancreatitis prefer the fetal positionigfor pain relief. B Spinal deformity usually affects the patient’s gait or causes a slumped posture. C Back painig usually affects the patient’s gait or causes a slumped posture. D Breathingigdifficulty is associated withigthe tripod position, whichigallows maximali g expa nsion of the muscles ofigrespiration. DIF: CognitiveLevel:Remember REF: 37TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE 3. Thetemperature of a patient is measured every 6 hoursat 6 AM,12 PM, 6 PM, and 12 AM.Wh ichigtemperature reading is expected to be low due to a normal variation? a. The measurementigat6 AM b. The measurement at 12 PM c. The measurement at 6 PM d. The measurementigat12 AM ANSWER: A Feedback A Early in the morning is the time of the lowest temperature of the day due tocircad ianigrhythms. B Aiglow temperature due to circadian rhythms is not expected at this time. C The highest temperature occurs inigthe late afternoon and early evening due tocircadi anigrhythms. D Aiglow temperature due to circadian rhythms is not expected at this time. DIF: CognitiveLevel: Understand REF: 38TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. Which statement is correct regarding taking or interpreting axillary temperatures? a. Axillary temperatures should not be used in patients less than 2 years of age. b. Readings may belessaccurate. c. Thethermometer is left inigplace for no morethan 3 minutes. d. The thermometer is placed inigthe axilla withthe shoulder abducted. ANSWER: B Feedback A The axillaigisa common site for temperature measurement on infantsand children. B Multiple studies have shown temperature measurements at the axillary site arei g l ess accurate compared with alternative sites. C The thermometer isleft inigplace until the audible signal occursand thetemperature appears on the screen. D Place the probe inigthe middle of the axilla, with the arm held against the body(adducte d). DIF: CognitiveLevel: Understand REF: 39TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 5. Aigtemperature of 99.8°F taken in the axilla is equivalent to which temperature value take n orally? a. 100.8°F b. 99.8°F c. 98.8° F d. 97.8°F This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00 https://www.coursehero.com/file/20908989/c4/
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER: A Feedback A Normal temperature readings fromthe axilla areabout 1°F belowthe normal orali g te mperature. B Normal temperature readings from the axilla are about 1° F below the normal ora ltemperature. C Normal temperature readings fromthe axilla areabout 1°F belowthe normal orali g te mperature. D Normal temperature readings from the axilla are about 1° F below the normal ora ltemperature. DIF: Cognitive Level:Apply REF: 39TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 6. The nurse suspects anigirregularity in the rhythm ofigthe patient’s radial pulse. What is the mosti g appr opriate actionigfor this nurse to take at this time? a. Document this rhythm as normal for the patient. b. Use a Doppler to check the brachial pulse. c. Count thepatient’sapical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4. ANSWER: C Feedback A Anigirregular rhythm isnotig aignormal finding. The pulsation between each beatshouldig be the same or regular. B AigDoppler isnotigindicated inigthiscase; it isused when the pulse cannot bepalpated. C Wheniganigirregular pulseis palpated, the nurse counts the number of pulsations for aigfulligminute. D Counting the radial pulse again for 15 seconds andigmultiplying by 4 may reconfi rmigthe initial findings, but does not provideadditional data for the nurseon this pati ent. DIF: Cognitive Level:Apply REF: 39TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System SpecificAsses sments 7. The patient with a respiratory rate that is within normal limits is the whoserespiratoryrate is breaths/min. a. 16-month-old; 36 b. 6-year-old; 20 c. 14-year-old;26 d. 40-year-old; 10 ANSWER: B This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Feedback A Aigtoddler’s respiratory rate ranges from 24 to 32. B Aigschool-age child’s respiratory rate ranges from 18 to 26. C An adolescent’s respiratory rate ranges from 12 to 16. D An adult’s respiratory rate ranges from 12 to 20. DIF: Cognitive Level:Apply REF: 40TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 8. Aignurse is taking vitaligsigns ofigan adult patient whose oxygen saturationigis 96%. The patient’s temp erature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 bre aths/min. Which factor may be contributing to the elevated respiratory rate? a. The patient’s temperature b. The patient’s oxygen saturation c. The patient’spulse rate d. The patient’s blood pressure ANSWER: A Feedback A Fever is a factor that may increase respiratory rate, and this patient’s temperature is102° F. B The patient’s oxygen saturation is a measure of the oxygen carried by hemoglobi ni g and it is within expectediglimits—above 90%. C The patient’s pulse rate may bedue to the highigtemperature, but a pulse of 100does n ot contribute to an elevated respiratory rate in this case. D The patient’s blood pressure is higher thanignormal, butigdoes not contribute toaneleva tedigrespiratory rate in this case. DIF: Cognitive Level:Apply REF: 40TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 9. Nurses understand that a patient’s diastolic pressure represents which physiologic function? a. The pressure needed to open theaortic and pulmonic valves b. The pressure inblood vessels when the ventricles contract c. The pressure of the blood returning to the heart fromigthe venous system d. The pressure inigbloodigvessels whenigthe ventricles are relaxed ANSWER: D Feedback A The pressure neededigto open theaortic andigpulmonic valvesis called theafterload. B The pressure in blood vessels wheni g the ventricles contract is the definition ofigthe systolic pressure. C The pressure of the bloodigreturning to the heart fromigthe venous systemigisincorrect. This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: CognitiveLevel: Understand REF: 41TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 10. According to research findings, whichigsite is preferred for measuring blood pressure whenigthenu rse is unable to use the patient’s upper arms? a. Ankle b. Thigh c. Calf d. Wrist ANSWER: A Feedback A Aigstudy comparing accuracy amongigsites recommended the ankle as ani g alternative site for blood pressure measurement. B The thighi g is anig alternative site, buti g the ankle is the preferred site. C A study comparing accuracy among sites recommended the ankle site in preference tothe calfigas anigalternative site for bloodigpressure measurement if theupp er arm is unavailable. D Approaches to measuring blood pressure using the wrist and finger sites have been developed, but these lack acceptable accuracy and cost efficiency to bereco mmended for clinical practice. DIF: CognitiveLevel:Remember REF: 41TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 11. Aig patient’s blood pressure has been averaging 120/72 when using the upper arms. Today th enurse uses this patient’s thigh to measure the bloodigpressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120? a. A systolic reading of 110 mm Hg b. Aigsystolic reading of 120 mm Hg c. Aigsystolic reading of 140 mm Hg d. Aigsystolic reading of 170 mm Hg ANSWER: C Feedback A A systolic reading of 110 mm Hg is too low. B A systolic reading of 120 mm Hg is too low. C Normally the systolic blood pressure is 10 to 40 mm Hg higher in the leg than ini g t he arm. D A systolic reading of 170 mm Hg is too high. DIF: Cognitive Level:Apply REF: 41 This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00 D The pressure in blood vessels whenigthe ventricles are relaxed is the definition ofthe d iastolic pressure.
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 12. Aignurse notices that the patient has gained 11 lb. If this increase inigweight is related to fluidi g reten tion, the patient is retaining approximately how many liters of fluid? a. 1 L b. 5 L c. 11 L d. 24 L ANSWER: B Feedback A Everykgigequals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. B Everykilogram (kg) equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. C Everykgigequals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. D Everykg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. This answer is obtainedig by multiplying 11 by 2.2 instead of dividing. DIF: Cognitive Level:Apply REF: 43TOP: NursingProcess:Assessment MSC:NCLEX:Patientig Needs:Physiologic Integrity:PhysiologicAdaptation: FluidandElectrolytei g Imbala nces MULTIPLERESPONSE 1. Which method of temperature measurement indirectly reflects inner core temperatur e? Select all that apply. a. Axillary temperature b. Oral temperature c. Tympanic temperature d. Rectaltemperature e. Temporal artery temperature ANSWER: B, E Correct: Inner core temperature is measured indirectly because the probe is placed near an arte ry. For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature. Incorrect: For axillary, tympanic, andi g rectal temperatures, the probe is not placed close to any major blood vessels. DIF: CognitiveLevel: Understand REF: 38TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Which method of temperature measurement does a nurse choose when assessing childre n?Select all that apply. a. Axillary temperature b. Rectaltemperature This study source was downloaded by 100000838401522 fromigCourseHero.comigon 03-03-2022 08:50:15 GMT -06:00
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE c. Temporal artery temperature d. Oral temperature e. Tympanic membrane temperature ANSWER: A,igC, D, E Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children. Incorrect: Rectal temperature measurement is considered safe and accurate for adults only. DIF: Cognitive Level:Apply REF: 38- 39TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 3. Which actionigby the nurse results in the patient’s blood pressure measurement being falselyhigh ? Select all that apply. a. Using a blood pressure cuff that is too narrow for the patient’s upper arm b. Deflating the blood pressure cuff too rapidly c. Wrapping the blood pressure cuff too loosely d. Reinflating the blood pressure cuff before it completely deflates e. Positioning the patient’s arm above the level of the heart ANSWER: A,igC, D, E Correct: Using aigblood pressure cuff that is too narrow for the patient’s upper arm, wrappingi g t he cuff too loosely, reinflating the cuff before it completely deflates, and positioning the pat ient’s arm above the level ofthe heart all result in readings that are falsely high. Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low. DIF: CognitiveLevel:Remember REF: 43TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. Which actionigby the nurse results in the patient’s blood pressure measurement being falselylow ? Select all that apply. a. Using a blood pressure cuff that is too wide for the patient’s arm b. Not inflating the blood pressure cuff enough c. Positioning the patient’s arm above the level of the heart d. Wrapping the cuff too loosely around the arm e. Deflating the cuff too rapidly ANSWER: A,igB, E Correct: Usingiga blood pressure cuff that is too widefor the patient’sarm, not inflating theblood pr essure cuff enough, and deflating the cuffigtoo rapidly couldigresult inigaigfalse low reading. Incorrect: Positioning the patient’s armigabove the level of the heart and wrapping the cuff too l oosely around the arm causes the bloodigpressure to be falsely high. DIF: CognitiveLevel:Remember REF: 43TOP: NursingProcess:Assessment MSC: NCLEX:Patient Needs: Physiologic Integrity: ReductionigofigRiskigPotential:SystemigSpecific This study source was downloaded by 100000838401522 fromigCourseHero.com on 03-03-2022 08:50:15 GMT -06:00 https://www.coursehero.com/file/20908989/c4/
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Assessments 5. The nurse taking a patient’s blood pressure recognizes that several factors may cause an increa sed blood pressure reading. Which factors below canincrease bloodigpressure? Selectig alli g that appl y. a. The patient ratespain at a leveligof7 on a scale of0 to 10. b. The cuff was reinflated before being completely deflated. c. The patient drankigcold milk just before thereading. d. The time of day is late afternoon. e. The cuff is too wide for the extremity. ANSWER: A,igB, D Correct: Rating pain at a level ofig7 onigaigscale ofig0 to 10, reinflating the cuff before being comple tely deflated, andigtaking the reading iniglate afternoon are all factorsthat canigincreasebloodigpressure . Incorrect: Drinking coldigmilkigjust before the reading willignot affect bloodigpressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuffigmakes thei g readingiglower th anigit actuallyis rather thanighigher. DIF: Cognitive Level:Apply REF: 43TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments COMPLETION 1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighedi g 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has los t Lfrom fluid loss. ANSWER: 3.6 1 kg (2.2 lb) = 1 L; 187 – 179 = 8 lb weightigloss divided by2.2 = 3.6 L. DIF: Cognitive Level:Apply REF: 43TOP: NursingProcess:Assessment MSC:NCLEX:PatientNeeds:Physiologic Integrity:PhysiologicAdaptation: FluidandElectrolyteImbala nces This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
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IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Chapter5:Ethnic,Cultural,andSpiritualConsiderationsi g Testig Bank MULTIPLECHOICE 1. What are the characteristics of one’s culture? a. Color of skin and hair b. System of beliefs and practices c. Food preferences d. Language and religion ANSWER: B Feedback A Skinigand hair color are examples of racial characteristics based on genetics. B System ofigbeliefsandigpractices is part of thedefinition of culture. C Food preferences are an example of ethnicity. D Language and religion are examples of ethnicity. DIF: CognitiveLevel:Remember REF: 47TOP: NursingProcess:Assessment MSC: NCLEXPatient Needs:Psychosocial Integrity: Cultural Diversity 2. Which example below best characterizes a patient’s race ? a. The language spoken in the patient’s home is Tagalog. b. The patient’s family followsaigkosher diet. c. The patient andighisigfamily haveblonde hair and fair skin. d. The patient’s grandparents came to the United States from Germany. ANSWER: C Feedback A The language spoken at homerefersto ethnicity. B Aigkosher diet refers to ethnicity. C Blonde hair and fair skinigindicate geneticsand race. D Althoughigthe patient and grandparents may share the same race, that the grandpare nts came tothe UnitedigStates fromigGermany does notigrelate torace. DIF: CognitiveLevel: Understand REF: 47TOP: NursingProcess:Assessment MSC: NCLEXPatientigNeeds:Psychosocial Integrity: Cultural Diversity 3. After the death of a Native American man, the nurse opened a window to allow spirits to leave. This action is an example of which attribute ofigthe concept of cultural competence ? a. Adapting interventions based on cultural practices (Tailoring) b. Gaining information about cultural differences (Knowledge) c. Considering the effects of another’s values and experiences (Understanding) d. Showing appreciation for cultural differences (Respect) ANSWER: A
IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE This study sourceigwas downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00 https://www.coursehero.com/file/20909004/c5/

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test bank for health assessment for nursing practice 7th edition by wilson-1-50.pdf

  • 1. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson Chapter 1 - 24
  • 2. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD Chapter01:IntroductiontoHealthAssessment MULTIPLE CHOICE 1. Aigpatientigcomesigto the emergencydepartmentigandigtellsthe triage nursethatigheis “havinga heart attack.” What isigthe nurse’stop priorityatigthistime? a. Determinethepatient’spersonalig data andi g insu rance coverage. b. Ask the patientigtotake a seatiginigthewaitingro omiguntil hisname iscalled. c. Requestigthata nursecollectigdataigfor aig c omprehensive history. d. Ask aignurseto startigafocusedigassessmenti g o fthispatient now. The nurse needs to beginigan assessment as soon as possible that is focused on this patient’si g ca rdiovascular system. The type of health assessment performed by the nurse is also driveni g by patient need. Personal data and insurance information will be obtained, but inigthis situation, t hese data canigwaitiguntil after the patient is assessed. Based also on Maslow’s hierarchy of ne eds, physiologic needs take precedence. Rather thanigasking the patient to wait, the nurse nee ds to beginigdata collection, such as vital signs, immediately to determinethe patient’s health status. Complications can be prevented if anigimmediate assessment is made to analyze the pa tient’s symptoms. A comprehensive history is notigindicated inigthis situation at this time. Som e subjective data will be collected, suchigas allergies andigmedical history relatedigto cardiovasc ular disease. Eyes, ears, or a complete musculoskeletal or mental healthassessment is not a p riorityat thisigtime. DIF: Cognitive Level: Apply REF: Box 1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment:Managementof Care:Establishin gPriorities 2. Which situationigillustratesiga screeningassessment? a. A patient visits anigobstetric clinic for the firs tig timeandig the nurseconductsaigdetailedi g history and physicaligexamination. b. Aighospital sponsorsa health fair atigalocalig mall and provides cholesterol and bloodigp ressure checksto malligpatrons. c. The nurse inanigurgent care center checksi g t he vital signs of aigpatient who is complain ingofiglegigpain.
  • 3. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igA A healthigfair at a localigmall that provides cholesterol and blood pressure checks is an exampl e of a screening assessment focusedigonigdisease detection. A detailed history and physical exa minationconductedigduringiga first- time visit to anobstetric clinic is anexampleof a comprehensive assessment. Assessing a pati ent complaining of leg painiginigthe triage area of anigurgent care center is anigexample ofiga prob lem- based/focused assessment. A patient’s return appointment 1 month after today’s office visit t o reportigfasting blood glucose levelsisanigexample ofiganigepisodic or follow-up assessment. DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionigandigMaintenance: HealthScreening 3. For whichigpersonisa screeningassessment indicated? a. Thepersonigwho hadabdominal surgery yesterday b. The personigwhois unaware ofighisig highi g s erumigglucose levels c. The personigwho isigbeingadmitted to aig l ong-termigcare facility d. The personigwho isbeginning rehabilitationi g af ter a knee replacement A screening assessment is performed for the purpose of disease detection. In this case thisp erson may have diabetes mellitus. A shift assessment is most appropriate for the personigwh o is recoveringiginigthe hospital fromigsurgery. A comprehensive assessment is performedi g duri ngigadmissionigto a facility to obtain a detailed history and complete physical examination. A n episodic or follow- up assessment is performed after knee replacement toevaluate the outcome ofigthe procedure . DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gigPriorities 4. For whichigpersonigisaigshiftigassessmentigindicated? a. Thepersonigwho hadabdominal surgery yesterday b. The personigwhoisunaware of hishighs erumigglucose levels c. The personigwho isbeingadmitted to a long-termcare facility d. The personigwhoisbeginningrehabilitationi g a fter aigknee replacement A shiftigassessment is most appropriate for the person who is recovering in the hospital fromi g s d. Aigpatient newly diagnosed withigdiabetesig mellitus comes to test his fastingigblood g lucoselevel. ANSWER:igB
  • 4. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE urgery. Aigscreening assessmentigis performed for the purpose ofigdisease detection, in this case diabetesmellitus. Aigcomprehensive assessmentisperformedigduringigadmissionigtoa
  • 5. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igC ANSWER:igD facility to obtain a detailed history and complete physical examination. An episodic or foll ow- up assessment isperformedigafter kneereplacement to evaluate the outcome oftheprocedur e. DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 4TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment:Managementof Care:Establishin gPriorities 5. For whichigpersonigisaigcomprehensive assessment indicated? a. Thepersonigwho hadigabdominaligsurgery yesterday b. The personigwhois unaware ofighishighi g s erumigglucose levels c. The personigwho isbeingadmitted to aig l ong-termigcare facility d. The personigwho isbeginningrehabilitationi g af ter a knee replacement Aigcomprehensive assessment isperformed duringadmissiontoa facilityto obtain a detailed history and complete physicaligexamination. Aigshift assessment is most appropriatef or the person who is recovering in the hospital from surgery. A screening assessment is perf ormed for the purpose of disease detection, inigthis case diabetes mellitus. Anigepisodic or fol low- up assessment is performed after knee replacement to evaluate the outcome of the procedur e. DIF: Cognitive Level: Understand REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 6. For whichigpersonisani g episodic orfollow-upassessment indicated? a. Thepersonigwho hadabdominal surgery yesterday b. The personwho isunaware ofhishighs erum glucose levels c. The personigwho isbeingadmittedigto a long-termigcare facility d. The personigwho isbeginningrehabilitationi g af ter a knee replacement Anigepisodic or follow- up assessment is performed after the knee replacement to evaluate the outcome of the proce dure. A shift assessment is most appropriate for the person who isrecovering in the hospital fromigsurgery. A screening assessment is performed for the purpose ofigdisease detection, inigth isigcasediabetes mellitus. Aigcomprehensive assessment is performed during admissionigto a fa cility to obtain a detailed history and complete physicali g examination. DIF: Cognitive Level: Understand REF: Boxig1-
  • 6. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE 3 | p. 3TOP: NursingigProcess: Assessment
  • 7. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igD MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 7. Whichisanexample ofdata a nurse collectsduringa physicale xamination? a. The patient’si g lackigofighairand shinyskini g o ver bothigshins b. The patient’sstatedigconcernabout lackigofmo neyfor prescriptions c. Thepatient’scomplaintsofig tinglingi g s ensationsinigthe feet d. Thepatient’smother’s statementsthatig thep atientisverynervouslately The lack of hair andigshiny skin over bothigshins are objective data or signs thatigare part of the physical examination. Apatient’sconcernsabout lackigof moneyare subjective dataigandi g are pa rt of the health history. A patient’s complaints ofigtinglingigsensations in the feetigare subjective dataigandigare part of the health history. A patient’s family statements are consideredigsecondar ydata, are subjective data, and are part ofigthe healthhistory. DIF: Cognitive Level: Apply REF: Boxig1- 3 | p. 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs:Physiologic Integrity: Reductionigof RiskigPotential: SystemSpecific Assessments 8. The nursedocumentswhichinformationiginigthe patient’shistory? a. Thepatient’sskinigfeelswarmtothe touch. b. The patientigisscratchinghisigarm. c. Thepatient’stemperatureis100°F. d. Thepatientcomplainsofigitching. A patient’s complaint of itchingigis subjective information, whichigmeans it is a symptom an d is documented in the history. The patient’s warm skinigis objective information gathered b ythe nurse throughig palpation, isalso a sign, andigisdocumentediginig the physicali g examination. The patient’s scratchingigis objective information gathered by the nurse throughigobservation , is also a sign, andigis documented inigthe physicaligexamination. The patient’s elevated temp erature is objective information gathered by the nurse through measurement, isigalso a sign, andigisdocumented inigthe physical examination. DIF: Cognitive Level: Apply REF: p. 1 | p. 2 andigBox 1- 2TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 9. Whichpatient informationig doesthe nurse document inthe patient’sphysicali g as sessment? a. Slurredigspeech b. Immunizations c. Smoking habit d. Allergies
  • 8. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igD ANSWER:igA Slurredigspeech shouldigbe noticed by the nurse andigdocumented as objective data in the physi cal assessment. Data on immunizations are collected fromigthe patient, are subjective, and do cumented inthe history. A smokingighabit isinformationthat comes fromig the patient,i g makingigit subjective data that is documented in the history. Allergies are information that come fromigt he patient, makingit subjective data that isdocumented inigthe history. DIF: Cognitive Level: Apply REF: p. 1-2 andigBox 1- 2TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs: Safe andigEffectiveCareEnvironment:Managementigof Care:Establishin gPriorities 10. Aftercollectingigthe data,the nurse beginsdataiganalysiswithigwhichigaction? a. Clusteringigdata b. Documentingigsubjective data c. Reportinginformationigtoother healthigteamig members d. Documentingigobjective information After collectingdata, the nurse organizesor clustersigthe data so that the problemsigappearmore clearly. To cluster data,the nurse interpretsigthe assessmentigdataigcollected. Documenting subjective dataigis necessary for the medical record, but does notigprovide analy sis. Before reporting data to healthigteam members, the nurse clusters and interprets data. Doc umentingigobjectivedata isnecessaryfor the medical record, but does not provideanalysis. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.4 MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: EstablishingPriorities 11. Whichactivityillustratesthe concept ofprimaryprevention? a. Monthlybreast self-examination b. Annualigcervicalig(Papanicolaouigtest) examination c. Educationabout livingwithigasthma d. Exercisingthree timesigaigweek Exercising is an example of primary prevention that prevents disease from developingigby m aintaining aighealthy lifestyle. Monthly breast self- examination is an example of secondary prevention and screening efforts to promote early d etectionigof disease. Annual cervical (Papanicolaou test) examinationigis an example of secon dary prevention and screening efforts to promote early detection of disease. Teaching a patie nt how to live withi g a chronic disease such as asthma is an example of tertiary prevention dire ctedigtowardigminimizingigthe disability from chronic disease andighelping the patientigmaximiz e his or herhealth. DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5- 6TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthigPromotionigPrograms
  • 9. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igC ANSWER:igA ANSWER:igB 12. Aignurse is teaching a patientighow to manage chronic obstructive pulmonaryd isease (COPD). Thisinterventionisanigexample of whichiglevel ofighealthigpromotion? a. Primaryprevention b. Secondaryprevention c. Tertiaryprevention d. Riskigfactor prevention Teachingiga patientighow to live withiga chronic disease is anigexample of tertiary prevention dir ectedigtowardigminimizing the disability fromigchronic disease and helpingigthe patient maximiz e his or her health. The focus ofigprimary prevention is to prevent aigdisease from developingigb y promoting aighealthy lifestyle. Secondary preventionigconsists of efforts to promote early det ection of disease. Risk factor prevention is part of primary prevention thati g focuseson preventi ngdisease bymanagingrisk factors. DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5- 6TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthPromotionigPrograms 13. Whichigactivityillustratesigthe concept of secondaryprevention? a. Annualigmammogram b. Nutritionigclassesoniglow-fatcooking c. Educationigoniglivingwithigdiabetes mellitus d. Cardiac rehabilitationigafter coronaryarteryby passsurgery A mammogram screens for breastigcancer and is an example of secondary prevention to pro mote early detection of disease. Nutrition classes are an example of primary preventionto pr event a disease fromigdeveloping by promoting a healthy lifestyle. Education about diabetes mellitus is anigexample ofigtertiary prevention directed towardigminimizing the disability fromig chronic disease and helping the patient maximize his or her health. Cardiac rehabilitationigaft er coronary artery bypass surgery is an example of tertiary preventionigdirected towardigmini mizing the disability fromigchronic disease andighelping the patientigmaximize hisigor her healt h. DIF: Cognitive Level: Understand REF: Table 1-1 | p. 5- 6TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthigPromotionPrograms 14. Aigcommunityorganizationigsponsors a healthigfair to increase awareness ofcoloni g ca ncer. At the health fair, colorectal cancer screening kits are distributed, andighealth care profe ssionals answer questions, take blood pressure, andigdistribute literature. What level ofi g health preventionisbeingimplemented bythiscommunityorganization? a. Primary b. Secondary c. Tertiary d. Riskigfactor Secondary prevention consists of screening efforts to promote early detectionigof disease — in this scenario, colorectal cancer andighypertension. Primary preventionigis focusedigon preve ntingigdisease fromigdevelopingigthroughigthe promotionigofiga healthylifestyle. Tertiary
  • 10. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE prevention is directed toward minimizing the disability from chronic disease and helping the patient maximize hisor her health. Riskigfactor preventionig isig part ofprimary preventioni g that foc usesigonigpreventingdisease bymanagingrisk factors. DIF: Cognitive Level: Apply REF: Table 1-1 | p. 5- 6TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs: HealthigPromotionandigMaintenance: HealthPromotionigPrograms Pow er ed by TCPDFig (w w w.t p cd f.igo rg )
  • 11. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER: A ANSWER:igB Chapter02:Obtaining a HealthHistory MULTIPLE CHOICE 1. Which statement or question does the nurse use during the introductionig phase ofigthe interview? a. “I’mighereto learnmoreabout thepaini g y ou’re experiencing.” b. “Canyouigdescribe thepaini g that you’rei g e xperiencing?” c. “Iigheardigyou saythat the painigisig‘alligover’your body.” d. “What relievesthe painigyouigare having?” “I’mighere to learn more about the painigyou’re experiencing” is an example of the introductio n phase a nurse may use to explainigthe purpose ofigthe interview to a patient. “Can you descri be the painigthat you’re experiencing?” is an example of part of a symptomi g analysisthat occur sini g thediscussionigphase.“Iheard you saythat the painigis‘alligover’ your body” is an example o f a summary statement by the nurse that occurs in the summary phase. “What relieves the pai n you are having?” is an example of part of a symptom analysisthat occursinigthe discussionigp hase. DIF: CognitiveLevel: Apply REF: Boxig2-1 | p. 8- 9TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 2. Which statement isappropriate to use whenigbeginning aninterview withai g n ew patient? a. “Have youigeverbeenigapatient inthisclinicbef ore?” b. “Whatigis your purpose for comingigtothec linictoday?” c. “Tellmeaiglittle about yourselfand yourfamil y.” d. “Did youighave anydifficultyfindingthec linic?” “What is your purpose for comingigto the clinic today?” is anigopen- endedigquestion that focuses onigthe patient’sreasonigfor seeking care. “Have youigever been aigpa tientiginig thisclinici g before?” is aigclose- endedigquestion thatigyields a “yes” or “no” response. This questionigmay be askedigon the firstigv isit, but not as an openingigquestion for a health interview. “Tell me a little aboutigyourselfigandig your family” is an open- endedigquestion, but itigis too general, andigiti g isatigleastig twoquestions: one aboutig thepatientigandig a notheraboutigthefamily. “Didigyou have
  • 12. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igC ANSWER:igD any difficulty finding the clinic?” is a socialigquestion and does not focus onigthe patient’si g p urpose for the visit. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.8 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 3. Whichigstatementigbythe nursedemonstratesa patient-centerediginterview? a. “Iigneedigto complete this questionnaire ab out your medical and familyhistory.” b. “The hospital requires me to complete this assessment assoonaspossible.” c. “Tellmeaboutthe symptoms you’vebeeni g h aving.” d. “I’vehadigthesame symptomsthatigyou’ved escribed.” “Tell me aboutigthe symptoms you’ve been having” focuses onigthe needs of the patient so tha t the patient is free to share concerns, beliefs, andigvalues inighis or her own words. “I need to complete this questionnaire about your medicaligandigfamily history” focuses on thenurse’s n eed to complete the assessment rather than the needs of the patient. “The hospitali g requiresm e tocomplete thisassessment as sooni g aspossible” focusesoni g the nurse’sneedigtoi g meet hospital requirements rather than the needs of the patient. “I’ve hadigthe same symptoms thatigyou’ve described” focusesonthe nurse rather thanigonigthe patient. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.8 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 4. Whichquestionigisanigexample ofan open-ended question? a. “Have youexperiencedthispainigbefore?” b. “Doyouighave someone tohelp youig ati g h ome?” c. “Howmanytimesa daydo you use your inhaler?” d. “Whatigwere youigdoingwhenyou felt thep ain?” “What were you doingigwhen youigfelt the pain?” is a broadly stated questionigthat encourage s a free-flowing, openigresponse. “Have youigexperienced this painigbefore?” is closed- ended, which can obtainiga “yes” or “no” answer to the questionigwithout any additionaligdata . “Do you have someone to help youigat home?” is closed- ended, which canobtain a “yes” or “no” answer to the questionigwithout any additional data. “How many times a day do you use your inhaler?” is closed- ended, which can obtainiganiganswer of a specific number without anyadditional data.
  • 13. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD ANSWER:igB DIF: Cognitive Level: Understand REF: pp.10- 11TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 5. Aig nurse suspectsa femalepatientigisa victimigofig physicalabuse. Whichi g re sponse ismostlikelyto encourage the patient toconfide inthe nurse? a. “You’ve gotigaighugebruiseonigyour face. Did your husband hit you?” b. “That bruise looks tender. Iigdon’t know howpeople canigdo that toone another.” c. “Ifyourboyfriendighitigyou, youigcaniggetar estrainingorder against him.” d. “I’ve seenigwomenigwho have been hurtigbyb oyfriends or husbands. Does anyone hit y ou?” “I’ve seen women who have been hurt by boyfriends or husbands” is an example ofiga techniq uereferredto asig“permission giving” inigwhichigthe nurse communicatesthatitis safe to discuss uncomfortabletopics. “You’vegot a hugebruiseonig your face. Did your husbandi g hit you?” as sumes that domestic violence did occur, and the comment does not encourage the patient to divulge additional information. “That bruise looks tender. I don’t know how people can do t hat to one another” assumes that domestic violence did occur, and the comment does not enc ourage the patient to divulge additional information. “Ifigyour boyfriend has hit you, you can get aigrestraining order againstighim” assumes thatigdomestic violence did occur, andigthe comm ent does not encourage the patient to divulge additional information. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 10 MSC: NCLEXigPatient Needs: Psychosocial Integrity: Abuse/Neglect 6. Which technique used by the nurse encourages a patient to continue talkingi g d uringiganiginterview? a. Laughingandigsmilingigduringigconversation b. Usingphrases suchigas“Go on,” andi g “ Then?” c. Repeating what the patientigsaid, but using different words d. Askingigthe patient to clarifya point Using phrases suchigas “Go on” and “Then?” encourages the patient to continue talking. La ughing and smiling during conversationigmay show attentiveness during the interview,but d oes notencourage more talking. Rephrasingigwhat the patient has said isigrestatement.
  • 14. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igA Itconfirmsyourinterpretationofwhatigtheysaid, butdoesnot encourage additionaligtalking.Asking the patient to clarify a point is done when the information is conflicting, vague, or ambiguous. DIF: Cognitive Level: Remember TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 7. During the history,igthe patient states that she does not use many drugs.ig What isthe nurse’sappropriate response tothis statement? a. “Tell me aboutigthe drugs youigare usingig currently.” b. “Tosome people sixor sevenigisnotig many.” c. “Do you meanigprescriptiondrugsor illicitig drugs?” d. “Howoftenare youusingthese drugs?” “Tell me aboutigthe drugs youigare using currently” is anigopen- endedigquestion thatigallows patients to provide further data. “To some people sixigor seven is not many” is a commentigthat does notigaskiga question or obtain usefuligdata. “Do you meanigpr escriptionigdrugs or illicit street drugs?”isigaigclosed- endedigquestionigthatigyieldsdataigabout the typeofigdrugsi g usedi g only. “How often are you using th ese drugs?” asks about frequency of drug use, which is not useful until the drugsare known. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 8. A nurse is interviewingiga patient who was diagnosedigwith type 2 diabetes me llitus 6 months ago. Since that time, the patient has gained weight and her blood glucoselevel sigremain high. The nurse suspectsthatigthe patient isignoncompliant withigher diet. Whichresp onse bythe nurse enhancesdataigcollectioniginigthis situation? a. “Tell meabout what foodsyoueat andigthei g f requencyof your meals.” b. “What symptomsdo youignotice whenigyourb lood sugar levelsare high?” c. “Youi g need tofollow whatthe doctor hasi g p rescribedigto manage your disease.” d. “Tell me whatigyouig know about the cause ofi g ty pe 2 diabetes.” “Tell me aboutigwhat foods you eat andigthe frequency of your meals” gathers more data fromi the patient to help the nurse confirmigif noncompliance is the reasonigfor the weight gainigand h ighigglucoselevels.“What symptomsdo youignoticewhenigyourblood sugar levels
  • 15. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD ANSWER:igD are high?” does not help the nurse determine if the patient is noncompliant. It may be useful later when teaching the patient about her disease. “You need to follow what the doctor has p rescribed to manage your disease” does not provide additional data for the nurseand maybe viewed asauthoritarian and paternalistic. “Tell mewhat you knowaboutthe cause of type 2 diabetes” assumes that the reason for the weight gain and high glucose levels is a lack ofigkno wledge. A more therapeutic approach is to gather more data fromigthepatientabout how the d iabetes hasbeen managed. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 9. A male patient tellsthe nurse that he rarely sleepsmore thanig 4 hoursa nighti g an dighas not experienced any problems because of the lack of sleep. Which response by the nurs e ismost appropriate? a. “Thatigisiginteresting.” b. “Only4 hoursof sleep? How do youigstaya wake duringigthe day?” c. “Really? Everyone needs more sleep thani g t hat.” d. “DidIigunderstand that youigsleep4 hourse verynight?” “Did I understand that you sleep 4 hours every night?” is a reflectionigtechnique that allowsth e nurse to confirm and obtain additional information. “That is interesting” does not provide an opportunity for the patient to explainigany reasonigfor the number of hours of sleep. “Only 4 hours of sleep? How do you stay awake during the day?” questions the accuracy of the pat ient’s data and may not encourage the patient to give further details. “Really? Everyone nee ds more sleep thanigthat” canigbe perceived as argumentative, but doesnot encourage further data fromigthe patient. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 10. Which technique shouldigthe nurse use to obtain more data about a patient’si g v ague or ambiguousstatement? a. Laughingand smilingigduringigconversation b. Usingphrases suchigas“Go on,” and “Then?” c. Repeating whatigthe patientighas said, butig usingigdifferent words d. Askingthe patientigtoexplainigaigpoint
  • 16. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB Asking the patient to explainiga point is clarification, whichigis used to obtain more informatio n about conflicting, vague, or ambiguous statements. Laughingigand smiling during conversat ion may show attentiveness duringigthe interview, but does not help to clarifyvague informati on. Usingi g phrases suchas“Goon” and“Then?” encouragespatientsi g to continue talking, but d oes not help clarify. Rephrasingigwhat the patient has said is restatement. It confirms your int erpretation of what they said, but does not encourage additional talking. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 11. Whatigdoes the nurse say to obtain more dataigaboutiga patient’s vaguei g s tatement about diet suchas, “Mydiet’sokay”? a. “Eatingig a varietyof meats, fruits, andi g vegetab les eachigdayisimportant.” b. “Give me anig example ofi g the foods youig eati g i niga typicaligday.” c. “Go on.” d. “Doesyour diet meet your needsor doesiti g n eedigimprovement?” “Give me an example of the foods you eat in a typical day.” This statement asks the patienti g to clarify the vague statement, “My diet is okay.” “Eating a variety of meats, fruits, and vegeta bles each day isimportant.” While this statement istrue, it does not obtain data about what f oods the patient consumes. “Go on” encourages patients to continue talking, but does not hel p clarify what foods are consumed. “Does your diet meet your needs or doesit need improve ment?” Thisresponse does not help clarifywhat foodsthe patient eats.Also it containstwo qu estionsrather thanaskingigone questionigat a time. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 12. While givingiga history, a male patient describes several eventsout of orderth at occurred in different decades in his life. What technique does the nurse use to understandig the timeline ofthese events? a. Statethe order ofeventsasunderstoodigandi g a sk the patient to verifythe order. b. Draw conclusions about the order ofigeventsi g fr omigdata given. c. Askthepatient toelaborate aboutigthese events. d. Ask thepatient to repeat what he saidi g a bout these events.
  • 17. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igA State the order ofigevents as understood and askigpatient to verify the order is correct. This the rapeutic technique is usefuligwhen interviewing a patient who rambles or does not provide se quential data. Drawing conclusions about the order ofigevents is interpretation. Inigthis exampl e, the sequence of events is more relevant than aniginterpretation. The nurse mayhave difficult y interpreting an unclear sequence of events. Asking the patient to elaborate about these eve nts willignot provide order to the sequence of events. Asking the patient to repeat what he saidi about these eventswill not necessarilyprovide a sequenceofevents. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p.11 MSC: NCLEXigPatient Needs: Psychosocial Integrity:TherapeuticCommunications 13. A male patient is very talkative and shares much informationigthat is not rele vantigto his history or the reasonigfor his admission. Which actionigby the nurse improvesi g datac ollectioniginigthis situation? a. Terminatetheinterview. b. Useclosed-endedquestions. c. Ask the patient to stayonthe subject. d. Ask another nurse tocompletethei nterview. Using closed-endedigquestions is useful to obtain specific dataigwhen open- endedigquestionsarenot obtainingigthe neededdata. Terminatingtheinterviewisnotigbeneficial tothepatienti g andigdoes not allow dataigcollection. Askingigthe patient to stay on the subject is not therapeutic andigmay resultiginigless data collection. Asking another nurse to complete the interview may not be practical andiginterrupts the nurse- patientigrelationship that has beenigestablished. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 11 |igp. 12 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 14. A patient answers questions quietly and appears sad. While answering questi ons about her marriage, she begins to cry. Which response by the nurse is appropriatei g inig this s ituation? a. “Don’tcry! I’llcomebackigwhen you’ves ettled down.” b. “Iigonly have a few more questionsto ask,i g a ndthenigI’lligleave youigalone for a while.” c. “Everyone has ups and downs inigtheir marr iage. Whatigproblemsareyouighaving?” d. “Iigsee that you are upset. Is there s omethingyou’dlike todiscuss?”
  • 18. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA ANSWER:igD “Iigsee that you are upset. Is there something you’d like to discuss?” shows that the nurse is att entive to the patient’s feelings and does not make assumptions about the reasonigwhy the patie nt is crying. The cryingigmay signify additional data the nurse needs to collect during this inter view. “Don’t cry! I’ll come backigwhenigyou’ve settled down” is not a therapeutic response. T he nurse needs to support the patient rather thanigleave her. “I only have a few more questions to ask, and thenigI’ll leave you alone for a while” is not a therapeutic response. The nurse is m ore concerned about gettingigthe history thanigthe patient’s response.“Everyone has ups and do wns in their marriage. What problems are you having?” is not a therapeutic response. The nur se is assuming there are problems inigthe marriage instead of collectingmore data. DIF: CognitiveLevel: Apply REF: pp. 11-12 | pp. 11- 13TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 15. During aniginterview, a patient begins to cry and appears angry. Whichi g r esponse bythe nurse ismostigtherapeutic? a. “This topic prompted anigemotionaligresp onse,telligmewhat youarefeeling.” b. “Thistopic does not usuallycause suchani g em otionaligresponse.” c. “Calmigdownand tell mewhatigiswrong.” d. “Iigwilligleaveyoualone foraigfew minutessoy oucanigpull yourselfigtogether.” Acknowledging the patient’s feelings and encouraging their expressionigcommunicates acc eptance of the emotion. Crying is a naturaligbehavior and should be permitted. “This topic d oes not usually cause suchiganigemotional response” may be perceived by the patienti g as judg mental and it does not help the patient meet the current need. Encouraging the patient to sto p cryingigso that the nurse can help is not supportive of the patient’s current need. The therap eutic action is to postpone further questioning untiligthe patient is ready toproceed.Leavingigt he roomso that the patient canigbe aloneisnot supportive ofthe patient. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 12 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 16. In whichigsituationigis the nurse’s use of closed- endedigquestions mosti g appropriate? a. Whenclarifyingigvague or conflictingdata b. When obtaining a history fromiganigoverlyt alkative patient c. When encouragingiga patient to elaborateig ondetailsofighisor her history
  • 19. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB Whenobtaininga history fromiganoverly talkative patient, a nurse canig resort to closedendedi g qu estions to complete the data collectionigin a timely manner. Whenigclarifyingigvague and confli cting data, the nurse needs to use open- ended questions to obtain data. When encouraging the patient to elaborate on details of his or her history, the nurse needs to use open- ended questions to obtain the details. When collecting data about the current problem,the pat ient needs to describe the symptoms that brought him or her to seek help. These detailsare no tcollected withigclosed-ended questions. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 12 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 17. The nurse isinterviewing a womanig withigher husband present. The husbandi g a nswers the questions for the wife most of the time. What is the most appropriate therapeutic nursingactionigto hear the patient’s viewpoint? a. Continuetheinterview. b. Askthe husbandigto step out ofigtheroom. c. Ask another nursetocompletethe interview. d. Tellthewomanigtospeak up for herself. Askingigthe husband to step out ofthe roomigwill allow the patient to answer questionsinighero wn way. Continuingigthe interview is not a therapeutic actionigbecause the nurse needs to obtai n the patient’s answers to the questions. Askingiganother nurse to complete the interview does not solve the problem that the husband is answering questions for his wife. Tellingigthe woma n to speak up for herself does not solve the problemigand may interfere withigthe therapeutic rel ationship betweenthe patient andigthe nurse. DIF: Cognitive Level: Remember REF: pp.12- 13TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 18. A female Koreanig patient accompanied by her husband and soncomesi g to thei g e mergency department (ED) complaining of abdominal pain. The patient speaks and understa nds Koreanigonly. Whichigpersonigis the appropriate choice for the nurse to use to geti g a historyf romthispatient? a. Thepatient’shusband who speaksKoreanig andigEnglish b. The patient’ssonigwho speaks Koreanigandig English c. A male technicianwho worksinigthe ED who speaks Koreanigand English d. When collecting data about the currentig healthigproblem ANSWER:igB
  • 20. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igA A female interpreter who speaks Koreanigand English and is available by phone is the best ch oicebecause she canigcommunicatewiththe patient and isthe same gender asthe patient.The patient’s husband who speaks Korean and English is not the best choice because he is a fami ly member and may alter the meaning of what is said. The patient’s son who speaks Korean andigEnglish is not the best choice because he is a family member and may alter themeaningig ofigwhat is said. Aigmale technician working in the ED who speaks Koreanigand English is not a good choice because the patient may feel uncomfortable giving a history toa stranger who i smale. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 13 MSC: NCLEX Patient Needs: PsychosocialigIntegrity: Cultural Diversity | NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications 19. Which nurse demonstratesculturallycompetent care for a female patienti g fr omigRussia? a. Nurse Aigwho asks the patient about cultu raligfactorsthat influence healthcare b. Nurse B whointeractswithigeverypatienti g fromi g Russia inigthe same manner c. Nurse Cwho learnsthe cultural variableso feveryculture,igincludingRussia d. Nurse D who relies on her previous e xperience withigpatientsfromigRussia Asking the patient about cultural factors thatiginfluence healthigcare is demonstrating culturall y competent care, along with interacting withigeach patientigas a unique person whoi g is a produc t of past experiences, beliefs, andigvalues. Interacting with every patientigfromigRussiaigin the sa me manner does notigallow for the uniqueness of eachigpersonigwithin the same culture. Learni ng the culturaligvariables of every group encountered can be valuable but itigis impractical to l earn about alligcultures because eachigpatient is unique. Aigbetter approachigistoaskigpatientsabo uttheir beliefs. Relyingonigpreviousigexperience withpatientsfromigRussiaigdoes not allow for th e uniqueness ofeachigpersonwithinthe sameculture. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 13 MSC: NCLEXigPatient Needs: Psychosocial Integrity: Cultural Diversity 20. Forwhichpatient isigafocused healthighistorymost appropriate? a. Aig new patientigatthe healthclinic for ani g annua l examination d. Ai g femaleinterpreter who speaksKoreani g a nd Englishigandisavailable byphone ANSWER:igD
  • 21. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igC b. A patient admitted to the hospital withig vomitingand abdominaligpain c. Ai g patientigatthe healthigcare provider’si g o ffice for aigsport physical d. A patient discharged 11 months ago who is beingreadmittedigtoday A patient admitted to the hospital withigvomiting and abdominal painigbenefits from a focuse d healthighistory that limits data to the immediate problem. A new patient at the health clinic for an annual examinationigneeds a comprehensive history that includes biographicdata,rea sonigfor seekingigcare,igpresent healthigstatus,past medical history, familyhistory, personal andig psychosocialighistory, andiga review of alligbody. Aigpatient with a specific need, such as a spo rt physical, needs aighistory for an episodic assessment. Aigpatient dischargedigmonths ago w ho is being readmitted needs a history for a follow- up assessmentigthat generally focuses onigthe specific problem or problems thatigcausedigthe p atientigto be readmitted. DIF: Cognitive Level: Understand REF: pp.13- 14i g TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity: TherapeuticCommunications 21. A patientigtells the nurse atigthe clinic, “I can never seem to get warmiglatelya nd feel tiredigall the time.” The nurse records these dataigunder whichigsectionigof the healthhis tory? a. Past healthighistory b. Present healthstatus c. Reasonigfor seekingigcare (chiefcomplaint) d. Subjectiveassessmentdata The reason for seeking care (chief complaint) is the patient’s reason for seeking care (also ca lledigthe presenting problem). The patient’s reason for seeking care is often recordedigas aigdire ct quote. The past health history includes data about immunizations, surgeries, accidents, an d childhoodigillnesses. The present healthigstatus includes dataigthe nurse obtainsi g fromig the patie nt, oftenigusingi g a symptom analysis in which more dataigare collectedigabout thei g patient’s reason for seeking care. Subjective assessmentigdata include information from the patient. Inigthis ex ample, the patient expresses the reasonigfor seekingigcare, whichigis directlyquotedigand placedigi n quotationigmarks inigthe chief complaintigsectionigof the data sheet so that the patient’s reasonig for seekingigcare canigbe easilyidentified. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 14ig MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 22. Aigpatient comes to the ambulatory surgery center for an elective procedure this morning. While givingthe admissionighistory, the patient statesshe isallergic to latex.
  • 22. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igD ANSWER:igD Whatigisthe mostappropriate response bythe nurse at thistime? a. Removingall latexproducts fromigthe patient’sroom b. Usingpowdered gloves whenigprovidingig careto thispatient c. Informing the surgeonigthat the patient hast ype I hypersensitivityto latex d. Questioningigthepatient about symptoms experienced inthe past withiglatex Questioning the patient about symptoms experiencediginigthe past with latexigis the appropriate response. When patients indicate an allergy to a medicationigor substance, askigthemigto descri be whatighappens withigexposure to determine whether the reaction is aigside effect or anigallergi c reaction. Removing alliglatex products from the patient’s room is unnecessaryat thistime be cause thelatexi g allergy has notigbeeni g confirmed. Usingpowderedi g gloves whenigproviding care t o this patientigis unnecessary atigthis time because the latexigallergy has notigbeenigconfirmed. Inf orming the surgeonigthat the patient has type I hypersensitivity to latex is unnecessary atigthis t ime because the latex allergy has not been confirmed. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 15 MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infectionig Control: InjuryPrevention 23. A nurse is interviewingiga male patientigwho reports he has not had aigtetanusi mmunizationigin aboutig15 years because he had aig“badigreaction” to the last tetanus immuniza tion. What isigthe most appropriate response bythe nurse inigthiscase? a. Notifythe healthigcare provider that thisi g immu nizationigcannot be given. b. Document thatthe patientigisallergic totheteta nusvaccine. c. Givethe vaccineafter explainingig thati g adverse reactions are rare. d. Ask the patient to describe the “bad re action”tothe vaccineinigmoredetail. The nurse needs to collect more data about the reactionigfromigthe patientigto determine the type of reactionigexperienced. The nurse is trying to assess the relationship between the “reaction” reported by the patient andigan allergic reaction. The immunizationigshouldignotigbeeliminatedig atigthis time. Additionaligfacts are needed to determine the type of reactionigthe patient experie nced. Documentingigan allergy to the tetanus vaccine may be an error because there are insuff icientigdata to make that determinationatigthistime. Givingthe
  • 23. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igB vaccine maybe anerrorifthepatient isallergic tothe vaccine and additionaligdataig indicatesi g that maybe the case. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 15 MSC: NCLEXPatient Needs: HealthigPromotionigandMaintenance: HealthPromotion and Disease Prevention 24. A patientigadmitted with pneumoniaigreportsigthatigshe takes insulin for diabe tesmellitus. Inwhichigsectionigofig the historydoesig the nurse document the insulinandi g diabetes ? a. Past healthighistory b. Presentighealthstatus c. Reasonigfor seekingigcare (chiefcomplaint) d. Historyofpresentigillness The present healthigstatus documents the current health conditions, which include chronic dis eases andigmedications taken. Inigthis case, diabetes andigtakingiginsulin are not the reasonigfor se ekingigcare, but need to be managedigwhile the patient’s pneumonia is being treated because th ey may affect the patient’s recovery from pneumonia. The pastighealth history includes catego ries ofigchildhood illness, surgeries, hospitalizations, accidents or injuries, immunizations, an d obstetric history. The reasonigfor seeking care (chiefigcomplaint) is a brief statement of the pa tient’s purpose for requestingigthe services of a health care provider.i g History of present illness further investigates the history ofigthe present problem; bestigaccomplished byconductinga sy mptomiganalysis. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 15 MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Collaborationigwithi g I nterdisciplinaryTeam 25. A nurse is gettinga history fromi g a patient who isdisabled fromig rheumatoidi g ar thritis. Whichquestionigwilligprovidedata about thispatient’sigfunctional ability? a. “Whendid yourarthritissymptoms begin?” b. “How hasyour arthritisaffected your dailylif e?” c. “Whydid youcome tothe clinic today?” d. ”Howdo you feel about your diagnosisofi g rhe umatoid arthritis?” “How has your arthritis affected your daily life?” is a questionigthat leads to data aboutigthep atient’s ability to performigself- care activities or functional abilities. “Whenigdid your arthritis symptoms begin?” is aigquest ion askedigas partigof the history, but does notigcollectigdata about functional ability. “Whydid youigcome tothe clinic today?”isaigquestionigasked
  • 24. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER:igB ANSWER:igD to obtainigthe chiefigcomplaint about a current problem, but doesnot focusdirectlyonthefunctional assessment. “Howdo you feel about your diagnosisofrheumatoid arthritis?” isa questionig to ask inig the psychosocial history, but does not focusdirectlyonig the functionali g assessment. DIF: CognitiveLevel: Apply TOP: NursingProcess: Assessment REF: p. 17 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications is: history 26. Anigexample ofigahealthpromotionigquestionigincludediginthe health a. “Do you have anyallergies?” b. “Howoftenare youigexercising?” c. “Whatigare you doing to relieve your legig pain?” d. “Whatigkindofigherbsare you using?” “Howoftenigare youigexercising?”isa questionigaboutactivitiespatientsregularlyperformigtomai ntain health. “Do youighave any allergies?” is a question for the present health status rather th an healthigpromotion. “What are you doingigto relieve your leg pain?” is a questioni g that is part ofigthe symptom analysis. “What kind ofigherbs are you using?” is a question forthe present he althigstatusrather thanighealthpromotion. DIF: Cognitive Level: Remember TOP: NursingProcess: Assessment REF: p. 17 MSC: NCLEXigPatient Needs: Psychosocial Integrity:TherapeuticCommunications 27. The patient reports having a persistent coughigfor the past 2 weeksi g a nd that the cough disrupts sleep and has not been helped by over-the- counter coughmedicines. Whichigquestionigismost appropriatefor the nurse toask n ext? a. “So whatigdo youthinkigis causingthisi g persiste ntigcough?” b. “Have youigtried takingsleepingpillstohel p youigsleep?” c. “Did youigthinkigthiswill just go awayonigitsi g ow n?” d. “Whatig other symptoms have younoticedi g r elatedto thiscough?” “What other symptoms have you noticed related to this cough?” is part of a symptomiganalysi s to provide more data. The answer to the question “So what do youigthinkigis causingthis persi stent cough?” is a guess by the patient and does not provide useful data. “Have you tried taki ngsleepingigpillsto help youigsleep?” does not focusonigthecough, whichis
  • 25. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE what is disturbing the patient’s sleep. “Did you think this will just go away onigits own?”d oesnot provide useful data andcriticizesthe patient’slack ofaction. DIF: CognitiveLevel: Apply REF: p. 18 | Boxig2- 3TOP: NursingigProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications MULTIPLE RESPONSE 1. Whichdata do nursesdocument under the headingofigPast HealthHistory?(S elect all that apply.) a. Father hasAlzheimer disease. b. Last tetanusinig2009 c. Had chickenpoxigasa child d. Drinksthree to four beerseachday e. Hadiga dentaligexamination6 monthsago ANSWER:igB, C, E Lastigtetanus is anigimmunization, chicken poxigas a child is aigchildhood illness, andiglast exam inations, including dental, are documentedigunder the heading of PastigHealth History.Famil y History documents father’s Alzheimer disease; patient drinking three to four beersi g each d ay refers to alcohol use, which is documentedigunder the heading Personal andigPsychosociali History. DIF: Cognitive Level: Understand REF: pp.15- 16TOP: NursingProcess: Assessment MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 2. Whichig dataigdo nursesdocumentigunder the headingofPersonal andi g P sychosocial History? (Select all that apply.) a. Walks for 45 minuteseachday b. Eatsmeats, vegetables,andfruit at two mealsdaily c. Isigallergic to milkandigmilkigproducts d. Isi g marriedigandighasig two daughterswhomighei g i sclose to e. Smokesmarijuana onceaweek f. Grandfatherdied fromigprostatecancer ANSWER:igA, B, D, E Walks for 45 minuteseachdayisdocumented under healthpromotionactivityinPersonali g and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is documented abo ut diet activity in Personal and Psychosocial History; is married and has two daughters who m he is close to is documented under family and social relationship activity in Personal and Psychosocial History; smokes marijuana once a weekigis documented underpersonalighabitsac tivityinigPersonal andPsychosocial History.Allergic
  • 26. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE to milk and milk products is an allergy, which is documented under the heading Presenti g H ealth Status; Grandfather diedigfrom prostate cancer is documented under the headingigFa milyHistory. DIF: Cognitive Level: Understand TOP: NursingProcess: Assessment REF: p. 16 MSC: NCLEXigPatient Needs:Psychosocial Integrity:TherapeuticCommunications 3. Whichquestionsi g are pertinent toaskwheni g obtaining a symptomanalysisi g fr omigapatient who reportsbreathingigproblems? (Select all that apply.) a. How long have youighad thisproblemigwithi g y our breathing? b. Do you have a family history of breathing problems? c. Doesthisbreathingig problemcome and goi g o r isigit constant? d. Whatigdo youigdoto make your breathingig better? e. How doesi g thisbreathingig problemaffecti g y our work or dailyactivities? f. How manypacksofig cigarettesdo youi g s moke a day? ANSWER:igA, C, D, E How long have youighadigthis problem with your breathing?, Does this breathing problemigco me and go or is itigconstant?, Whatigdo you do to make your breathingigbetter?, and Howdoes this breathing problem affect your workigor daily activities? are questions askediginiga sympto m analysis. Use the mnemonic ofOLDCARTS (e.g., onsetigof symptoms, locationand durati onigof symptoms, characteristics, aggravating factors, related symptoms, treatment used, an d severity ofigsymptoms). Do you have aigfamily history of breathing problems? Thisquestio nigrelatesto the patient’sighistory; How many packs ofigcigarettesigdoyou smoke aigday? Thisigqu estionigrelatestothe patient’s history. DIF: CognitiveLevel: Apply REF: p. 17 | Boxig2- 3TOP: NursingigProcess: Assessment MSC: NCLEXPatient Needs:Physiologic Integrity: Reductionigof RiskigPotential: SystemSpecific Assessments 4. Whichquestionsi g are pertinent toaskwheni g obtaining a symptomanalysisi g fr omigapatient who reportsa headache? (Select all that apply.) a. Describewhatthe headache feelslike. b. Whenigwasyourlastigeye examination? c. Whatigmakesigthe headachesworse?
  • 27. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE d. How do youigrate the headaches on a scalei g o f 0 (meaning no pain) to 10 (meaning thei g w orse painigever)? e. Do you have anysymptomswiththeh eadaches, suchasnausea? f. Whendid youfirst noticethe headaches? ANSWER:igA, C, D, E, F Describe what the headache feels like?, What makes the headaches worse?, How do youigrat e the headaches on aigscale ofig0 (meaning no pain) to 10 (meaning the worse pain ever)?,i g Do y ouighave any symptoms with the headaches, suchigas nausea?, and Whenigdidigyouigfirst notice t he headaches? are questions askediginiga symptomiganalysis. Use the mnemonic of OLDCAR TS(e.g., onsetigofig symptoms, locationig andig durationig ofig symptoms, characteristics,i g aggravating f actors, related symptoms, treatmentigused, and severity of symptoms). When wasyour last ey eexamination? assumesthat the headachesigare related to a visionproblem.Last eye examinat ion isigdocumentedigin the history under the heading of PastigHealthigHistory. DIF: CognitiveLevel: Apply REF: p. 15 | Boxig2- 3TOP: NursingigProcess: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction ofigRisk Potential: Systemig Specific Assessments 5. Which questions are pertinent for a nurse to ask a patient while performingai review ofthe cardiovascular system? (Select allthat apply.) a. Do youremember what your last cholesterol valuewas? b. Have youighad chest painigor shortnessofb reath? c. Do youhave trouble breathingwhen youi g li e down? d. Are your feet cold, numb,or do they changecolor? e. Howmuchigdo youigweigh? f. Have youignoticedigedemainyouranklesatt he end ofthe day? ANSWER:igB, C, D, F Have youighadigchestigpain or shortness ofigbreath?, Do you have trouble breathingigwhen youiglie down?, Are your feet cold, numb, or do they change color?, and Have youignoticedigedema inig your ankles atigthe end of the day? are questions asked to give the patientigan opportunity to re portigsymptoms of the cardiovascular system. Do you remember what yourlast cholesteroligva lue was? relates to aiglab value, whichig isobjective data not documentedigini g the history; How mu chigdo youweigh? isobjective data not documentediginthe history. DIF: Cognitive Level: Remember REF: p. 18
  • 28. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE TOP:NursingProcess: Assessment MSC: NCLEXPatient Needs: Physiologic Integrity: Reductionigof RiskigPotential: SystemSpecific Assessments
  • 29. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Chapter3:TechniquesandigEquipmentforPhysicaligAssessmentTe st Bank MULTIPLECHOICE 1. What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? a. Cleani g the bell andi g diaphragm of the stethoscope between patients. b. Perform handighygiene. c. Wear gloves when anticipating exposure to body fluids. d. Wear eye protection wheniganticipating spatter of body fluids. ANSWER: B Feedback A Cleaningigthe bell andigdiaphragm of the stethoscope betweenigpatientsis importanti g to prevent the spread of microorganisms whenigauscultating only. B Consensus recommendations of the World Health Organization include use of hand hygiene techniques to prevent spread of microorganisms before palpating,p ercussing, or auscultating patients, and during patient care. C Wearing gloves when anticipating exposure to body fluids is important to preventig the spread of microorganisms from the patient while giving care. D Wearing eye protectionigwheniganticipating spatter of body fluids is important topreven tigthe spreadigofigmicroorganisms fromigthe patient while giving care. DIF: CognitiveLevel:Remember REF: 21TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Safe andEffectiveCareEnvironment: Safetyand InfectionControl:Standar digPrecautions/Transmission-BasedigPrecautions/SurgicaligAsepsis 2. When examiningaigpatient, the nurse remembers to follow whichigprinciple of Standardi g Pr ecautions? a. Wear gloves throughout the entire examinationi g of the patient. b. Wear gloves when inigcontact withigthe patient’s mucousmembranes. c. Wear glovestoreducethe needfor handwashing. d. Wear eye protection andig a gown during the examination of the patient. ANSWER: B Feedback A Wearing gloves throughout the examination of the patient is unnecessary. Referring to the Standard Precautions for the correct answer; nurses use judgmen ti g to determine when contact with body fluids is possible. B Specifically, this applies to contact with blood, body fluids (e.g., urine, feces,i g sput um, woundigdrainage), nonintact skin, and mucous membranes. C Hands must bewashed after removal of gloves. D The nurse should wear a mask with eye protectionigor a face shield during procedur es that may result in splashes or sprays of the patient’s blood, body fluids, secretions, or excretions.
  • 30. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: CognitiveLevel: Understand REF: 22TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Safe andigEffective Care Environment: Safety and Infection Control: Standard/Transmission-Based/Other Precautions 3. Howdonurses preventigaiglatexigallergy? a. They usenonlatex gloves for all procedures. b. They protect their hands using oil-based hand lotion applying latex gloves. c. They use a powder-free, low-allergen latex gloves. d. They wash their hands with mild soap and dry thoroughly before applying latexi g gl oves. ANSWER: C Feedback A Nonlatex gloves may be used only for activities that are not likely to involvecont act withiginfectious materials. B NIOSH recommendsnotig using oil-basedighandiglotions when wearing latexiggloves. C Use of these typesigofiggloves is recommended by The National Institute forOccupation al Safety andigHealth (NIOSH). D NIOSH recommends washing hands after removing latex gloves, not before applying them. DIF: CognitiveLevel:Remember REF: 22, Box 3- 2TOP: NursingigProcess:Assessment MSC: NCLEXigPatient Needs: Safe andEffectiveCareEnvironment: Safetyand InfectionControl:Standar digPrecautions/Transmission-BasedigPrecautions/SurgicaligAsepsis 4. Whichexplanationig is most appropriate for aignurse preparing to palpate aigpatient’s neck? a. “I need to feel for tumors in your neck.” b. “I’m going to feel your neck for any abnormalities.” c. “I need to press deeply on your neck so please hold still.” d. “Is there any tenderness ini g your neck?” ANSWER: B Feedback A I need to feel for tumors in your neck” uses the term “tumors” and may alarm the patient unnecessarily. B Palpatingigthe neck entersthe patient’s personal spaceand may have cultural significance. Thus it isimportant to inform patientsof the impending action andits purpose. C “Ineed to press deeply on your neckigso please holdigstill” may alarm the patient andigis not accurate. To palpate the neck, light palpation is usedigto detect abnormalit ies such as enlarged nodes. Deep palpation is used oni g the abdomen. D “Is there any tenderness in your neck?” obtains subjective data, but does not telli g th e patient what the nurse is planning to do. DIF: Cognitive Level:Apply REF: 23TOP: NursingProcess:Assessment MSC: NCLEXPatient Needs: HealthPromotionigandigMaintenance:TechniquesofigPhysical
  • 31. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Assessment 5. Which nurse is performing the technique of light palpation appropriately? a. Nurse Aigapplies the bimanual technique to determine size andiglocation of thepati ent’s heart. b. Nurse B uses the fingertips to feel for temperature differences on the patient’s legs. c. Nurse C places the ulnar surface of the hands onigthe patient’s thorax to detecti g vibr ations. d. Nurse D depresses the patient’s abdomen approximately 4 cm to assess pulsations. ANSWER: C Feedback A The bimanual technique is used to entrap an organ or mass (such as the uterus or a growth) between the fingertips to determine size and location and is notpalpati on. B Temperature differences are best detected using the dorsal surface of the hand;i g t his technique is not palpation. C Nurse C places the ulnar surface of the hands onigthe patient’s thoraxigto detecti g vibration s. This is considerediga light palpation. D Light pulsation is performed by pressing in to a depth of approximately 1 cm,rath er thanig4 cm. DIF: CognitiveLevel: Understand REF: 23TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 6. How does the nurse perform the bimanual technique of palpation to assess organs? a. Using the palmar surface of the dominant hand to pressinwardto a depth of abouti g 1 c m b. Holding a light source in one hand while strokingthe skiniglightly withthedo minant hand c. Using the ulnar surfaces of both hands to press inward 4 to 5 cm d. Using both hands, one anterior and one posterior, to entrap an organigbetweenigthefing ertips ANSWER: D Feedback A Usingigthe palmar surface ofigthe dominant hand to press inward to a depth of about 1 cmigdescribeslight palpation, whichigis differentigfrom the bimanualtechnique. B Holdingiga light source in one hand while stroking the skin lightlywith thedominant hand isused when inspecting rather than palpating. C Using the ulnar surfaces of both hands to press inward 4 to 5 cm describes ani g inco rrect technique. D Using both hands, one anterior and one posterior, to entrap an organig between thef ingertips is the correct technique for bimanual palpation. DIF: Cognitive Level:Apply REF: 23-24
  • 32. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 7. While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel co oler thanigthe upper extremities. To confirmigthis suspicion, how does the nurse compare thetemper atures of the lower extremities with the upper extremities? a. Using the backs (dorsum) of the hands to detect differences b. Using the ulnar surface of the hands to detect differences c. Using the pads of the fingers to detect differences d. Using the palmar surface (underside) of the hands to detect differences ANSWER: A Feedback A The dorsal surfaces of the hands detect temperature best. B The ulnar surfaces ofigthe hands arethemost sensitive to vibration. C The pads ofthe fingers are used in palpation. D The palmar surfaces (underside) of the fingers and finger pads are better fordeter mining position, texture, size, consistency, masses, fluid, and crepitus. DIF: Cognitive Level:Apply REF: 23TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 8. Howdoesa nurse assess for fluid inigaigpatient’s abdomen? a. Placing the nondominant hand (pleximeter) over the area to be percussed, and stri king the index finger of the pleximeter withig the padi g of the middle finger ofigthed ominant hand b. Applyingindirect percussion bytapping one finger lightly onigthe abdominal wallwi th the plexor c. Placing the middle finger of the nondominant hand (pleximeter) over the area to bepe rcussed, andigstriking that finger with the tip ofigthe middle finger ofigthe dominanthand d. Using direct percussion by placing one hand over the abdomen and striking lightlywi th the other hand ANSWER: C Feedback A Onlythe finger being struckigtouches theareaigto be percussed; the other fingers are raised off the skinigandigthe middle finger is struck withigthe tip ofthe finger ofi g the o ther hand. B Percussing theabdomen requires bothighands, one asigtheplexor andigthe other asthe pleximeter. C Placing the middle finger of the nondominant hand(pleximeter) over theareato be percussed, and striking that finger with the tip of the middle finger of thedomi nant hand describes the correct technique. D Using directigpercussionigby placingigone hand over theabdomen and strikinglightly withigthe other hand does not describe the correct technique.
  • 33. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: Cognitive Level:Apply REF: 24TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 9. What assessment data do nurses obtainigthrough striking a hand directly againstigthe flank orco stovertebral angle of a patient’s body? a. Fluid in the lungs b. Tendernessoverthe kidneys c. Air inigthe abdomen d. Tendernessovertheliver ANSWER: B Feedback A Fluid in the lungs is detected byindirect percussion. B Tenderness over the kidneys is detected by direct percussion over thecostovertebral angle. C Air in the abdomen is detected by indirect percussion. D Tenderness over the liver is detected by palpation. DIF: Cognitive Level:Apply REF: 24TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 10. Aigpatientighas been complaining of abdominal cramping and gas; the nurse notes that his abd omenigis slightly distended. Whichigsound doesthe nurseexpect tohear during percussionofthis patient’s abdomen? a. Flatness b. Dullness c. Resonance d. Tympany ANSWER: D Feedback A Flatness is heardigover bonesand muscle. B Dullness is heardig over the liver. C Resonance is heard over normal lung tissue. D Tympany is a loud, high-pitched sound heard over the abdomen. DIF: Cognitive Level:Apply REF: 24- 25TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 11. The nurse isunable to hear the patient’s breath sounds. What checks does thenurse make ofi g the stethoscope to determine the cause of this problem? a. Ensure the stethoscope tubing is at least 20 incheslong.
  • 34. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE b. Ensure the valve is open to the diaphragm on the head of the stethoscope. c. Ensure the earpieces are pointed toward the back ofigthe ears. d. Ensure the bell is placed firmly against the patient’s skin. ANSWER: B Feedback A Tubing shouldigbe no longer thanig12 to 18 inches. Ifthetubing islonger than 18inches , the sounds may become distorted. B The diaphragmigis usedigto hear high- pitchedigsounds, suchas breath sounds, boweli g sounds, and normal heart sounds. Its st ructure screens out low-pitched sounds. C Earpieces areangledig towardig the nose so thatigsoundig is projectedig towardig thei g tympanic membrane. D The bell ofthe stethoscope isused to hear soft, low- pitched sounds such as extrai g heart sounds or vascular sounds (bruit). DIF: Cognitive Level:Apply REF: 27TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 12. What part ofthe stethoscope do nursesuse toauscultate the chest? a. Press the bell firmly against the skin to hear sounds and vibrations. b. The bell ofigthe stethoscope isused to hear breath sounds. c. The diaphragm of the stethoscope is used to hear heart sounds. d. Either the belligor the diaphragm isusedig to auscultate the chest. ANSWER: C Feedback A The bell shouldigbe pressediglightly onigthe skin withigjust enough pressure to ensuretha t a complete seal exists around the bell. If the bell is pressed too firmly onigthei g skin,i the concave surface is filled with skin, and the bell functions like a diaphragmigandiginhibits vibrations. B The bell isused to hear soft, low- pitched sounds such as extra heart sounds orvascular sounds (bruit). C The diaphragm is used to hear breath sounds, bowel sounds, and normal hearti g sou nds (high-pitchedigsounds). D Either the bell or the diaphragm is used to auscultate the chest. The diaphragm isu sed to hear breath sounds, bowel sounds, andignormal heart sounds(high-pitched sounds). DIF: CognitiveLevel: Understand REF: 27TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 13. How doesthe nurse detect an extra heart sound in an adult? a. Using the bell of a stethoscope b. Withiga pulse oximeter c. Using the diaphragm of a stethoscope
  • 35. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE d. With a Doppler ultrasound probe ANSWER: A Feedback A The bell ofthe stethoscope isused to hear soft, low- pitchedigsounds such as extrai g heartigsounds or vascular sounds (bruit). B Pulse oximetry is a noninvasive measurement of arterial oxygen saturation in theig blood. C The diaphragmigisused to hear high- pitchedigsounds such asbreathigsounds, bowelsounds, and normal heartigsounds. D AigDoppler ultrasoundigprobe is usedigto detect difficult-to- hear vascular soundsi g such as fetal heart tones or peripheral pulses. DIF: CognitiveLevel:Remember REF: 27TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 14. A nurse is preparing to take a patient’s blood pressure. The blood pressure cuff is 5 inches wi de and the patient’s upper arm circumference is 20 inches. How accurate will this patient’s b loodigpressure be using this bloodigpressure cuff? a. Accurate, theactual value b. Higher thantheactual value c. Lower than the actual value d. Unable to determine accuracy withavailable data ANSWER: B Feedback A For an armigcircumference that is 20 inches, theproper size cuffigisat leastig8 inches(20 0.40 = 8).Therefore the blood pressure measurement will not be accurate. B For an arm circumference that is 20 inches, the proper size cuffigis at least 8 inche si g (20 0.40 = 8). The cuffigis 5 inches, whichi gis too narrow. A cuff that is too narrow will overestimate the blood pressure and report a falsely high value. C For an armigcircumference that is 20 inches, theproper size cuffigisat leastig8 inches(20 0.40 = 8). Therefore the blood pressure measurement will be higher than the actual value. D Sufficient data provided to determine accuracy. For an armi g circumference that i si g 20 inches, the proper size cuff isat least 8 inches (20 0.40 = 8). DIF: Cognitive Level:Analyze REF: 29TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 15. Wheredoesthe nurse attachigthe sensor probeofigthe pulseoximeter to measure a patient’si g ox ygenigsaturation? a. The chest over the patient’sheart b. Over the patient’s abdominal aorta
  • 36. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE c. Overthepatient’s radial pulse d. Around the patient’s index finger nail ANSWER: D Feedback A The chestigover the patient’s heartigisig anig incorrectigoptionigbecause the LED wouldi g not be able to reflect off oxygenatedand deoxygenatedighemoglobin molecules circulatingiginigblood. B Over the patient’s abdominaligaorta is anigincorrect optionigbecause the LED wouldi g not be able to reflect off oxygenated and deoxygenated hemoglobinigmolecules circul ating inigblood. C Over a patient’s radial pulse is an incorrect option because the LED would not be able to reflect off oxygenated and deoxygenated hemoglobin moleculescirculat ing in blood. D The sensor is taped to a highly vascular area, such as around the index finger nail that allowsthelight- emitting diode (LED) to reflect off oxygenated anddeoxygenated hemoglobin mole cules circulating inigblood. DIF: CognitiveLevel:Remember REF: 29TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 16. The patient asks about the meaning of his visual assessment of 20/40 using a Snellen visu aligacuity chart. What is the nurse’s appropriate response? a. “20/40 means your vision isabout two times normal.” b. “Aigperson with corrected vision can see at 20 feet what you canig see at 40 feet.” c. “Aigperson with normal vision can see at 20 feet what you can see at 40 feet.” d. “Aigperson with normal vision can see at 40 feet what you can see atig20 feet.” ANSWER: D Feedback A This isanincorrect interpretation ofthedata. B This isanincorrect interpretation ofthedata. C This isanincorrect interpretation ofthedata. D The top number ofigthe recording indicates the distance betweenthe patientigand the chart, and the bottom number indicates the distance at which aigpersonigwithi g norm al vision should be able to read certain letters of the chart. DIF: Cognitive Level:Apply REF: 30- 31TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 17. The nurse is using the Snellenigchart to assess a patient’s vision. The patient states that the gr eenigline on the chart is shorter thanigthe redline. What isthe interpretation ofigthis finding? a. This patient hasnormal color perception andigabnormal field perception. b. This patient is color blindigbut has normal fieldigperception. c. This patient’s color perception and field perception are normal.
  • 37. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE d. This patient is color blind and has abnormal field perception. ANSWER: A Feedback A Naming the colors of the horizontal lines is a screening for color perception. The top line is green, and the bottomigline is red. Asking which line is longer is ascreenin g for fieldigperceptionigmeasurement. The green line is longer. B This isanincorrect interpretation ofthedata. C This isanincorrect interpretation ofthedata. D This isanincorrect interpretation ofthedata. DIF: Cognitive Level:Apply REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 18. What tool does the nurse use to assess the patient’s near vision? a. AigSnellen eye chart placed about 12 inches from the patient’s face. b. An ophthalmoscope withigthe diopter set atig0 (zero). c. AigJaeger or Rosenbaum chart placed about 2 feet from the patient’s face. d. Aignewspaper held about 14 inches from the patient’s face. ANSWER: D Feedback A A Snellen chart is used to assess distant vision. B Anigophthalmoscope isused to assesstheinternal eye. C This is incorrect because of the distance specified. These charts can be used toass ess near vision whenigplacedigatig14 inches from the patient’s face. D This can be analternative tousingiga Jaeger or Rosenbaum chart held at 14 inchesfro m the face. DIF: CognitiveLevel:Remember REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 19. Using an ophthalmoscope, how does the nurse bring a patient’s interior eye structures int o focus? a. Using the red filter b. Adjusting the diopters c. Dilatingthepatient’s pupils d. Using the wide-beam light ANSWER: B Feedback A The redigfilter facilitatestheidentificationigofig pallor ofigthe disc and permitstherecogni tion ofretinal hemorrhages bymaking the bloodigappear black. B The lens selector dial (diopter) allows the nursetoadjust a set ofiglenses thatcontrols f ocus.
  • 38. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE C When the patient’s pupils are dilated, a larger light may be used for the internali g e ye examination. D The wide beamiglight canigbe used when the patient’s pupilsare dilatedigfor bettervisual ization of internal structures. DIF: CognitiveLevel: Understand REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 20. Which action by the nurse describes the correct technique for using an otoscope on an adult? a. Using the pneumatic attachment to observe for tympanic fluctuation b. Striking the otoscope against thehand to engage c. Instructing theadult to raise one finger when aigsound isigheard d. Selecting thelargest size speculumigthat fitsinto theadult’s ear canal ANSWER: D Feedback A The pneumatic attachment is used to evaluate the fluctuation of the tympanicme mbrane inigchildren. B The otoscope is not struck. The instrument that is struck before hearingi g assessmen t is a tuning fork. C Instructing thepatient to raise one finger wheniga sound is heard isdone whenusing anigaudiometer to assess hearing. D Using the largest speculum allows visualization, while using a smaller speculum limitsinspectionigandigusing aigspeculum that is too large isuncomfortable to theadult. DIF: CognitiveLevel: Understand REF: 31TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 21. Aignurse is preparing to assess a patient’s ability to detect vibrations. Which piece of equ ipmentigis appropriate for this assessment? a. Reflexighammer b. Tuning fork c. Goniometer d. Monofilament ANSWER: B Feedback A Aigreflex hammer is used to test for deep tendon reflexes. B The tuning forki g is used to assess the patient’s ability to detect vibration. C Aiggoniometer is used to measure the degrees of flexion and extension of a joint. D Aigmonofilament is used to test for sensation on the lower extremities. DIF: CognitiveLevel:Remember REF: 33TOP: NursingProcess:Assessment
  • 39. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 22. To test deep tendon reflexes, the nurse uses which instrument? a. Goniometer b. Calipers c. Reflexighammer d. Monofilament ANSWER: C Feedback A Aigmonofilament is usedi g to test for sensation oni g the lower extremities. B Calipers are used to measure thickness of subcutaneous tissue to estimate theamo unt of body fat. C Aigreflex hammer is used to test deep tendon reflexes. D Aigmonofilament is usedi g to test for sensation oni g the lower extremities. DIF: CognitiveLevel:Remember REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 23. Aignurse isusing the finger padsto palpate a patient’s dorsalis pedis pulses andigis unable tofeel any pulses. Whichigactionigis appropriate for the nurse to perform next? a. Document that the dorsalis pedispulsesare not palpable. b. Have the patient stand and try again to palpate the pulses. c. Use a Doppler to detect the presence of the pulses. d. Palpate the dorsalis pedis pulsesusing the ulnar surfaceof the hand. ANSWER: C Feedback A Document that the dorsalispedis pulses arenot palpable. Althoughigthe pulse may not be palpable, the nurse always tries a Doppler to determine if the pulse canigbeh eard, even whenigit cannot be felt. B Have the patient stand and try again to palpate the pulses. Changing positions wil lnot facilitate palpation ofiga pulse. C Use a Doppler to detect the presence of the pulses. The Doppler uses ultrasonicw aves to detect difficult-to-hear vascular sounds, such as peripheral pulses. D Palpate the dorsalis pedis pulses using the ulnar surface of the hand. The ulnarsur face ofthe hand isused to palpate for vibrations rather than pulsations. DIF: Cognitive Level:Analyze REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 24. How does the nurse detect aigpulse when usingiga Doppler? a. The pulsationigis felt. b. The pulsation isheard.
  • 40. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE c. The pulse wave is seenigoniga screen. d. The pulse waveisprintedigout on specialigpaper. ANSWER: B Feedback A AigDoppler is used when the pulses cannot be palpated. B AigDoppler amplifies sounds difficult to hear with an acoustic stethoscope. C AigDoppler amplifies the sound of the pulsation. D AigDoppler amplifies the sound of the pulsation DIF: CognitiveLevel:Remember REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 25. A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which i nstrument/tool does the nurseuse to measure the degree of flexionigand extension of thepati ent’s knee joints? a. Calipers b. Ruler or tape measure c. Goniometer d. Doppler ANSWER: C Feedback A Calipers are used to estimate the amount of body fat. B Aig ruler or tape measure cannot accurately measure the degree of flexion andi g extensio n ofigjoints. C Aiggoniometer is usedi g to measure the degree of flexion and extension ofiga joint. D Doppler is used to detect the presence of pulses. DIF: CognitiveLevel: Understand REF: 33TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 26. Whenigdoesiga nurse choose to use skinfold calipers whenigcollecting assessment data? a. Calculating the patient’s body mass index b. Inspecting the patient’s skin c. Determining the amount of the patient’s lean body tissue d. Estimating the amount of the patient’s body fat ANSWER: D Feedback A Body massindex isaigformula for determining obesitythat is calculated bydividingi a person’s weight in kilograms bythe height in meters. B Calipers estimate body fat. They are not needed to inspect skin. C There is no specific method to determine the amount of lean body tissue.
  • 41. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: CognitiveLevel:Remember REF: 34TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 27. Whenigdoes a nurse useaigPederson or Graves speculum for examination ofigaigpatient? a. To inspect the external ear b. To assess the vaginal canal c. To inspect nasal passages d. To assess the oropharynx ANSWER: B Feedback A The external ear isinspectedigusing anigotoscope. B The vaginaligcanal andigcervix are inspected using a Pederson or Graves speculumi g or a pediatric or virginal speculum. C The nasaligpassages areinspected using a nasal speculum. D The oropharynx isiginspectedigusing a tongue bladeand penlight. DIF: CognitiveLevel:Remember REF: 34TOP: NursingProcess:Assessment MSC: NCLEXigPatientigNeeds: Health Promotion and Maintenance: Techniques of Physicalig Assessment 28. What arecharacteristics ofanig audioscope? a. Screens for hearing ability b. Allows visualization intotheear canal c. Must be calibrated beforeuse d. Uses vibrationigto estimate hearingigloss ANSWER: A Feedback A Anigaudioscope screens for hearing ability. B The otoscope allowsinspectionigof the ear canal. C Calibration is unnecessary. An audioscope needs batteries that are charged. D The tuning fork is thetool that uses vibrationigto detect hearingloss. DIF: CognitiveLevel:Remember REF: 35TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 29. Aigpatient withigtype 2 diabetes mellitus hasaninfected lesion on his foot. Duringthe history ofi g his present illness, he reports, “I had a cut on my foot, but I did not even feel it.” What equipment does the nurse use to gather more data about his foot? a. AigWood lamp D Estimating the amountigof the patient’s body fat isigthe purpose of using skini g calipers.
  • 42. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE b. Transilluminator c. Monofilament d. Reflexighammer ANSWER: C Feedback A AigWood lamp is used to detect fungal infection on the skin. B Aig transilluminator differentiates the characteristics of tissue, fluid, and air withi nig aspecific body cavity. C A monofilament is used to test for sensation on the lower extremities. Becauset his patient could not feel the cut onighis foot, perhaps he haslost sensation. D Aigreflex hammer is used to test for deep tendon reflexes. DIF: Cognitive Level:Apply REF: 35TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 30. A patient is complaining of pain over the maxillary sinuses. Which device does the nurse us e to determine ifthere is air or fluid in the patient’s sinuses? a. Magnification device b. Transilluminator c. Monofilament d. Woodiglamp ANSWER: B Feedback A A magnification device helps visualize the tissue, but will not determine if sinuse si g are filled with air or fluid. B Aig transilluminator disseminates its light source under the surface of the skin to determine if the areasunder the surface, such as the sinuses, are filled withigair,fluid, or tissue. C Aigmonofilament is used to test for sensation oni g the lower extremities. D AigWood lamp is used to detect fungal infections. DIF: CognitiveLevel: Understand REF: 35TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment 31. Aignurse suspects that a large skiniglesion on the patient’s forearm is a fungal infection. Whichi g devi ce does the nurse use to confirm his suspicion? a. Peniglight b. Magnification device c. Transilluminator d. Woodiglamp ANSWER: D Feedback
  • 43. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE A Aigpeniglight is usedigto highlightiga lesion for inspection, but will not determine if iti g i s caused bya fungus. B Aigmagnification device helpsvisualize thelesion, butigwill not determineifig it isi g cause d by a fungus. C Ai gtransilluminator disseminates its light source under the surface ofi gthe skin toi g det ermine ifigthe areaigunder the surface is filledigwith air, fluid, or tissue. D Skini g lesions caused by a fungal infection exhibit a fluorescent yellow- green orblue-green color when examined withiga Wood lamp. DIF: CognitiveLevel: Understand REF: 36TOP: NursingProcess:Assessment MSC: NCLEXigPatient Needs: Health Promotion and Maintenance: Techniques of Physicalig Assessment
  • 44. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Chapter4:GeneralInspectioni g andigMeasurementigofVitali g SignsTes t Bank MULTIPLECHOICE 1. Which body system does the nurse assess primarily by inspection? a. Respiratory b. Gastrointestinal c. Skin d. Cardiovascular ANSWER: C Feedback A The respiratory system is assessed primarily usingigauscultation, but also percussio nandinspection when observing paleor cyanotic skinigfromighypoxia. B The gastrointestinal system is assessed primarily by auscultation and palpation,i g bu t also with inspection when looking at the contour ofthe abdomen. C Skini g is assessed primarily using inspection, but also palpation. D The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of per fusion or edema. DIF: CognitiveLevel:Remember REF: 37TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Aigpatient issitting slightly forward bracing his armsonighis kneesiniga tripod position. Thispos ition is associated withigwhichigsymptom? a. Abdominaligpain b. Spinal deformity c. Back pain d. Breathing difficulty ANSWER: D Feedback A Positions used by patients with abdominal pain vary depending upon what organ isinvolved. For example, patients with appendicitis tendigtolieverystill; thosewithig acute pancreatitis prefer the fetal positionigfor pain relief. B Spinal deformity usually affects the patient’s gait or causes a slumped posture. C Back painig usually affects the patient’s gait or causes a slumped posture. D Breathingigdifficulty is associated withigthe tripod position, whichigallows maximali g expa nsion of the muscles ofigrespiration. DIF: CognitiveLevel:Remember REF: 37TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
  • 45. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE https://www.coursehero.com/file/20908989/c4/
  • 46. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE 3. Thetemperature of a patient is measured every 6 hoursat 6 AM,12 PM, 6 PM, and 12 AM.Wh ichigtemperature reading is expected to be low due to a normal variation? a. The measurementigat6 AM b. The measurement at 12 PM c. The measurement at 6 PM d. The measurementigat12 AM ANSWER: A Feedback A Early in the morning is the time of the lowest temperature of the day due tocircad ianigrhythms. B Aiglow temperature due to circadian rhythms is not expected at this time. C The highest temperature occurs inigthe late afternoon and early evening due tocircadi anigrhythms. D Aiglow temperature due to circadian rhythms is not expected at this time. DIF: CognitiveLevel: Understand REF: 38TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. Which statement is correct regarding taking or interpreting axillary temperatures? a. Axillary temperatures should not be used in patients less than 2 years of age. b. Readings may belessaccurate. c. Thethermometer is left inigplace for no morethan 3 minutes. d. The thermometer is placed inigthe axilla withthe shoulder abducted. ANSWER: B Feedback A The axillaigisa common site for temperature measurement on infantsand children. B Multiple studies have shown temperature measurements at the axillary site arei g l ess accurate compared with alternative sites. C The thermometer isleft inigplace until the audible signal occursand thetemperature appears on the screen. D Place the probe inigthe middle of the axilla, with the arm held against the body(adducte d). DIF: CognitiveLevel: Understand REF: 39TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 5. Aigtemperature of 99.8°F taken in the axilla is equivalent to which temperature value take n orally? a. 100.8°F b. 99.8°F c. 98.8° F d. 97.8°F This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00 https://www.coursehero.com/file/20908989/c4/
  • 47. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE ANSWER: A Feedback A Normal temperature readings fromthe axilla areabout 1°F belowthe normal orali g te mperature. B Normal temperature readings from the axilla are about 1° F below the normal ora ltemperature. C Normal temperature readings fromthe axilla areabout 1°F belowthe normal orali g te mperature. D Normal temperature readings from the axilla are about 1° F below the normal ora ltemperature. DIF: Cognitive Level:Apply REF: 39TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 6. The nurse suspects anigirregularity in the rhythm ofigthe patient’s radial pulse. What is the mosti g appr opriate actionigfor this nurse to take at this time? a. Document this rhythm as normal for the patient. b. Use a Doppler to check the brachial pulse. c. Count thepatient’sapical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4. ANSWER: C Feedback A Anigirregular rhythm isnotig aignormal finding. The pulsation between each beatshouldig be the same or regular. B AigDoppler isnotigindicated inigthiscase; it isused when the pulse cannot bepalpated. C Wheniganigirregular pulseis palpated, the nurse counts the number of pulsations for aigfulligminute. D Counting the radial pulse again for 15 seconds andigmultiplying by 4 may reconfi rmigthe initial findings, but does not provideadditional data for the nurseon this pati ent. DIF: Cognitive Level:Apply REF: 39TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System SpecificAsses sments 7. The patient with a respiratory rate that is within normal limits is the whoserespiratoryrate is breaths/min. a. 16-month-old; 36 b. 6-year-old; 20 c. 14-year-old;26 d. 40-year-old; 10 ANSWER: B This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
  • 48. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE https://www.coursehero.com/file/20908989/c4/
  • 49. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Feedback A Aigtoddler’s respiratory rate ranges from 24 to 32. B Aigschool-age child’s respiratory rate ranges from 18 to 26. C An adolescent’s respiratory rate ranges from 12 to 16. D An adult’s respiratory rate ranges from 12 to 20. DIF: Cognitive Level:Apply REF: 40TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 8. Aignurse is taking vitaligsigns ofigan adult patient whose oxygen saturationigis 96%. The patient’s temp erature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 bre aths/min. Which factor may be contributing to the elevated respiratory rate? a. The patient’s temperature b. The patient’s oxygen saturation c. The patient’spulse rate d. The patient’s blood pressure ANSWER: A Feedback A Fever is a factor that may increase respiratory rate, and this patient’s temperature is102° F. B The patient’s oxygen saturation is a measure of the oxygen carried by hemoglobi ni g and it is within expectediglimits—above 90%. C The patient’s pulse rate may bedue to the highigtemperature, but a pulse of 100does n ot contribute to an elevated respiratory rate in this case. D The patient’s blood pressure is higher thanignormal, butigdoes not contribute toaneleva tedigrespiratory rate in this case. DIF: Cognitive Level:Apply REF: 40TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 9. Nurses understand that a patient’s diastolic pressure represents which physiologic function? a. The pressure needed to open theaortic and pulmonic valves b. The pressure inblood vessels when the ventricles contract c. The pressure of the blood returning to the heart fromigthe venous system d. The pressure inigbloodigvessels whenigthe ventricles are relaxed ANSWER: D Feedback A The pressure neededigto open theaortic andigpulmonic valvesis called theafterload. B The pressure in blood vessels wheni g the ventricles contract is the definition ofigthe systolic pressure. C The pressure of the bloodigreturning to the heart fromigthe venous systemigisincorrect. This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
  • 50. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE https://www.coursehero.com/file/20908989/c4/
  • 51. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE DIF: CognitiveLevel: Understand REF: 41TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 10. According to research findings, whichigsite is preferred for measuring blood pressure whenigthenu rse is unable to use the patient’s upper arms? a. Ankle b. Thigh c. Calf d. Wrist ANSWER: A Feedback A Aigstudy comparing accuracy amongigsites recommended the ankle as ani g alternative site for blood pressure measurement. B The thighi g is anig alternative site, buti g the ankle is the preferred site. C A study comparing accuracy among sites recommended the ankle site in preference tothe calfigas anigalternative site for bloodigpressure measurement if theupp er arm is unavailable. D Approaches to measuring blood pressure using the wrist and finger sites have been developed, but these lack acceptable accuracy and cost efficiency to bereco mmended for clinical practice. DIF: CognitiveLevel:Remember REF: 41TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 11. Aig patient’s blood pressure has been averaging 120/72 when using the upper arms. Today th enurse uses this patient’s thigh to measure the bloodigpressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120? a. A systolic reading of 110 mm Hg b. Aigsystolic reading of 120 mm Hg c. Aigsystolic reading of 140 mm Hg d. Aigsystolic reading of 170 mm Hg ANSWER: C Feedback A A systolic reading of 110 mm Hg is too low. B A systolic reading of 120 mm Hg is too low. C Normally the systolic blood pressure is 10 to 40 mm Hg higher in the leg than ini g t he arm. D A systolic reading of 170 mm Hg is too high. DIF: Cognitive Level:Apply REF: 41 This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00 D The pressure in blood vessels whenigthe ventricles are relaxed is the definition ofthe d iastolic pressure.
  • 52. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE https://www.coursehero.com/file/20908989/c4/
  • 53. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 12. Aignurse notices that the patient has gained 11 lb. If this increase inigweight is related to fluidi g reten tion, the patient is retaining approximately how many liters of fluid? a. 1 L b. 5 L c. 11 L d. 24 L ANSWER: B Feedback A Everykgigequals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. B Everykilogram (kg) equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. C Everykgigequals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. D Everykg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. This answer is obtainedig by multiplying 11 by 2.2 instead of dividing. DIF: Cognitive Level:Apply REF: 43TOP: NursingProcess:Assessment MSC:NCLEX:Patientig Needs:Physiologic Integrity:PhysiologicAdaptation: FluidandElectrolytei g Imbala nces MULTIPLERESPONSE 1. Which method of temperature measurement indirectly reflects inner core temperatur e? Select all that apply. a. Axillary temperature b. Oral temperature c. Tympanic temperature d. Rectaltemperature e. Temporal artery temperature ANSWER: B, E Correct: Inner core temperature is measured indirectly because the probe is placed near an arte ry. For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature. Incorrect: For axillary, tympanic, andi g rectal temperatures, the probe is not placed close to any major blood vessels. DIF: CognitiveLevel: Understand REF: 38TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Which method of temperature measurement does a nurse choose when assessing childre n?Select all that apply. a. Axillary temperature b. Rectaltemperature This study source was downloaded by 100000838401522 fromigCourseHero.comigon 03-03-2022 08:50:15 GMT -06:00
  • 54. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE https://www.coursehero.com/file/20908989/c4/
  • 55. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE c. Temporal artery temperature d. Oral temperature e. Tympanic membrane temperature ANSWER: A,igC, D, E Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children. Incorrect: Rectal temperature measurement is considered safe and accurate for adults only. DIF: Cognitive Level:Apply REF: 38- 39TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 3. Which actionigby the nurse results in the patient’s blood pressure measurement being falselyhigh ? Select all that apply. a. Using a blood pressure cuff that is too narrow for the patient’s upper arm b. Deflating the blood pressure cuff too rapidly c. Wrapping the blood pressure cuff too loosely d. Reinflating the blood pressure cuff before it completely deflates e. Positioning the patient’s arm above the level of the heart ANSWER: A,igC, D, E Correct: Using aigblood pressure cuff that is too narrow for the patient’s upper arm, wrappingi g t he cuff too loosely, reinflating the cuff before it completely deflates, and positioning the pat ient’s arm above the level ofthe heart all result in readings that are falsely high. Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low. DIF: CognitiveLevel:Remember REF: 43TOP: NursingProcess:Assessment MSC: NCLEX: PatientigNeeds: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. Which actionigby the nurse results in the patient’s blood pressure measurement being falselylow ? Select all that apply. a. Using a blood pressure cuff that is too wide for the patient’s arm b. Not inflating the blood pressure cuff enough c. Positioning the patient’s arm above the level of the heart d. Wrapping the cuff too loosely around the arm e. Deflating the cuff too rapidly ANSWER: A,igB, E Correct: Usingiga blood pressure cuff that is too widefor the patient’sarm, not inflating theblood pr essure cuff enough, and deflating the cuffigtoo rapidly couldigresult inigaigfalse low reading. Incorrect: Positioning the patient’s armigabove the level of the heart and wrapping the cuff too l oosely around the arm causes the bloodigpressure to be falsely high. DIF: CognitiveLevel:Remember REF: 43TOP: NursingProcess:Assessment MSC: NCLEX:Patient Needs: Physiologic Integrity: ReductionigofigRiskigPotential:SystemigSpecific This study source was downloaded by 100000838401522 fromigCourseHero.com on 03-03-2022 08:50:15 GMT -06:00 https://www.coursehero.com/file/20908989/c4/
  • 56. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Assessments 5. The nurse taking a patient’s blood pressure recognizes that several factors may cause an increa sed blood pressure reading. Which factors below canincrease bloodigpressure? Selectig alli g that appl y. a. The patient ratespain at a leveligof7 on a scale of0 to 10. b. The cuff was reinflated before being completely deflated. c. The patient drankigcold milk just before thereading. d. The time of day is late afternoon. e. The cuff is too wide for the extremity. ANSWER: A,igB, D Correct: Rating pain at a level ofig7 onigaigscale ofig0 to 10, reinflating the cuff before being comple tely deflated, andigtaking the reading iniglate afternoon are all factorsthat canigincreasebloodigpressure . Incorrect: Drinking coldigmilkigjust before the reading willignot affect bloodigpressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuffigmakes thei g readingiglower th anigit actuallyis rather thanighigher. DIF: Cognitive Level:Apply REF: 43TOP: NursingProcess:Assessment MSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments COMPLETION 1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighedi g 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has los t Lfrom fluid loss. ANSWER: 3.6 1 kg (2.2 lb) = 1 L; 187 – 179 = 8 lb weightigloss divided by2.2 = 3.6 L. DIF: Cognitive Level:Apply REF: 43TOP: NursingProcess:Assessment MSC:NCLEX:PatientNeeds:Physiologic Integrity:PhysiologicAdaptation: FluidandElectrolyteImbala nces This study source was downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:50:15 GMT -06:00
  • 57. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE https://www.coursehero.com/file/20908989/c4/
  • 58. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE Chapter5:Ethnic,Cultural,andSpiritualConsiderationsi g Testig Bank MULTIPLECHOICE 1. What are the characteristics of one’s culture? a. Color of skin and hair b. System of beliefs and practices c. Food preferences d. Language and religion ANSWER: B Feedback A Skinigand hair color are examples of racial characteristics based on genetics. B System ofigbeliefsandigpractices is part of thedefinition of culture. C Food preferences are an example of ethnicity. D Language and religion are examples of ethnicity. DIF: CognitiveLevel:Remember REF: 47TOP: NursingProcess:Assessment MSC: NCLEXPatient Needs:Psychosocial Integrity: Cultural Diversity 2. Which example below best characterizes a patient’s race ? a. The language spoken in the patient’s home is Tagalog. b. The patient’s family followsaigkosher diet. c. The patient andighisigfamily haveblonde hair and fair skin. d. The patient’s grandparents came to the United States from Germany. ANSWER: C Feedback A The language spoken at homerefersto ethnicity. B Aigkosher diet refers to ethnicity. C Blonde hair and fair skinigindicate geneticsand race. D Althoughigthe patient and grandparents may share the same race, that the grandpare nts came tothe UnitedigStates fromigGermany does notigrelate torace. DIF: CognitiveLevel: Understand REF: 47TOP: NursingProcess:Assessment MSC: NCLEXPatientigNeeds:Psychosocial Integrity: Cultural Diversity 3. After the death of a Native American man, the nurse opened a window to allow spirits to leave. This action is an example of which attribute ofigthe concept of cultural competence ? a. Adapting interventions based on cultural practices (Tailoring) b. Gaining information about cultural differences (Knowledge) c. Considering the effects of another’s values and experiences (Understanding) d. Showing appreciation for cultural differences (Respect) ANSWER: A
  • 59. IF YOU NEED THE WHOLE OF THIS TESTBANK CLICK HERE IF ANY COMMMENTS OR NEED OF OTHER STUDY MATERIALS CLICK HERE This study sourceigwas downloaded by 100000838401522 from CourseHero.com on 03-03-2022 08:49:55 GMT -06:00 https://www.coursehero.com/file/20909004/c5/