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NSG 3160 EXAM 1 ALL VERSIONS COMBINED
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Which of the following actions/behaviors in the critical-thinking process are important for the novice nurse to remember? (Select all that apply.) a. Disregard initial cues b. Approach assessment with a nonjudgmental attitude c. Cluster associated assessment data d. Perform assessment in whatever manner works for you. e. Avoid making assumptions -- ANSWER--b, c, e The nurse should never make assumptions as they may bias data collection and selection of diagnoses. An important aspect to gain trust with the patient is to maintain a nonjudgmental attitude. Once all health assessment data has been collected, it is important to cluster signs and symptoms as this will help in the critical thinking and decision-making process regarding medical and nursing diagnoses. It also helps to categorize problems as the first, second, or third priority. The nurse should never disregard any cues. These are important in the critical thinking and diagnosis decision-making process. Novice nurses do not have enough experience to vary from the step-by-step process for health assessment data collection. As the nurse gains experience, he/she will learn when it's appropriate to vary the process.
An example of subjective data is a. decreased range of motion. b. crepitation in the left knee joint. c. arthritis. d. left knee has been swollen and hot for the past 3 days. -- ANSWER--d. left knee has been swollen and hot for the past 3 days. Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpating. Arthritis is a medical diagnosis. What type of database is most appropriate when the rapid collection of data is required and often compiled concurrently with lifesaving measures? a. Complete b. Focused c. Follow-up d. Emergency -- ANSWER--d. Emergency An emergency database includes the rapid collection of data often obtained concurrently with lifesaving measures. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is
The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the balance of the humors. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. The four humors of the body include the blood, phlegm, black bile, and yellow bile; the humors regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. When completing a health assessment, which of the following actions most demonstrates cultural competence? a. Ask about family history of diseases. b. Ask about use of traditional, herbal, or folk remedies. c. Make sure the blood pressure cuff fits appropriately. d. Measure height and weight in a private room. -- ANSWER--b. Ask about use of traditional, herbal, or folk remedies. Failing to ask about use of traditional, herbal, or folk remedies could lead to significant drug interactions. Use of a private room is not necessary for all ethnic/cultural groups. All patients should be asked about family history of diseases. This is a necessary aspect for health assessment of all individuals. It is important to make sure the blood pressure fits appropriately for all patients. Spirituality is defined as
a. a social group that claims to possess variable traits. b. participating in religious services on a regular basis. c. the process of being raised within a culture. d. a personal effort to find meaning and purpose in life. -- ANSWER--d. a personal effort to find meaning and purpose in life. A nurse precepting a student nurse asks, "What's the most important step in the criticalthinking process?" a. Clustering subjective and objective data b. Analyzing health data c. Using evidence-based assessment techniques d. Prioritizing health concerns -- ANSWER--c. Using evidence-based assessment techniques Evidence-based techniques are supported by research showing effectiveness of the technique that provides the safest and most current techniques to promote the health of patients. Clustering subjective and objective data is a step in the critical-thinking process, but is not the most important step. Analyzing health data is a step in the critical-thinking process, but is not the most important step. Prioritizing health concerns is a step in the critical-thinking process, but is not the most important step. What type of database is most appropriate for an individual who is admitted to a long-term care facility? a. Focused b. Complete c. Emergency
d. Bruising on lower leg -- ANSWER--b. Pain rated at 7 out of 10 Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Blood glucose is measured by using a drop of blood placed on a test strip in a glucometer. Bruising is assessed by inspection. Heart rate is assessed by palpation of the radial artery or auscultated with a stethoscope when listening to heart sounds. A complete database is a. used to collect data rapidly and is often compiled concurrently with lifesaving measures. b. used to evaluate the cause or etiology of disease. c. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. d. used to perform a thorough or comprehensive health history and physical examination. -- ANSWER--d. used to perform a thorough or comprehensive health history and physical examination. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An emergency database is a rapid collection of data often obtained concurrently with lifesaving measures. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. Medical diagnoses are used to evaluate the cause or etiology of the disease. A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?
a. Ineffective self-health management b. Impaired gas exchange c. Readiness for enhanced spiritual well-being d. Risk for infection -- ANSWER--b. Impaired gas exchange Spirituality is a personal effort to find purpose and meaning in life. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Ethnicity pertains to a social group within the social system that claims to possess variable traits. Which of the following statements regarding language barriers and health care is true? a. English proficiency is associated with a lower quality of care. b. Patients with language barriers have a decreased risk for nonadherence to medication regimens. c. Standards have been identified that are important to eliminate health disparities. d. LEP is associated with a higher quality of care. -- ANSWER--c. Standards have been identified that are important to eliminate health disparities. Title VI of the Civil Rights Act of 1964 provides people with LEP access to health care; these individuals cannot be denied health care services. The National Standards for Culturally and Linguistically Appropriate Services in Health Care are important to implement in order to improve quality of care and eliminate health disparities. LEP is associated with a lower quality of care. English proficiency is associated with a higher quality of care. Patients with language barriers have an increased risk for nonadherence to medication regimens.
Heritage consistency theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage. Behavior theory or behaviorism is a learning theory. Carl Rogers described the concepts of congruence and incongruence as important ideas in his theory of personality and human development. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Which of the social determinants of health has the greatest influence on a person's health? a. Work environment b. Neighborhood c. Education d. Poverty -- ANSWER--d. Poverty The social determinants of health are interconnected and affect a person's health. But, research has consistently shown that poverty has the greatest influence on health status. Each culture has its own healers who usually a. own and operate specialty community clinics. b. cost less than traditional or biomedical providers. c. recommend folk practices that are dangerous. d. speak at least two languages. -- ANSWER--b. cost less than traditional or biomedical providers.
Most healers cost significantly less than healers practicing in the biomedical or scientific health care system. Most healers speak the person's native tongue. Most healers make house calls. Most health practices used by folk healers are not dangerous and are usually harmless. Which of the following symptoms is greatly influenced by a person's cultural heritage? a. Food intolerance b. Hearing loss c. Pain d. Breast lump -- ANSWER--c. Pain Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain all are embedded in a cultural context. Hearing loss is more common in whites than in blacks. The incidence of breast cancer varies with different cultural groups. Food intolerance varies with different cultural groups. For example, lactose intolerance is common in African Americans, American Indians, and Asian Americans. When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the healthcare needs of others. These discrete areas include understanding of (Select all that apply.) a. his or her own heritage. b. cultural and ethnic values. c. the heritage of the health care system. d. the heritage of the nursing profession.
c. "I know just how you feel." d. "Why did you wait so long to make an appointment?" -- ANSWER--a. "Tell me what you mean by 'bad blood.'" "Tell me what you mean by 'bad blood'" is an appropriate communication technique referred to as seeking further clarification. "I know just how you feel" is an inappropriate communication technique referred to as false reassurance. "If I were you, I would have the surgery" is an inappropriate communication technique referred to as giving unwanted advice. "Why did you wait so long to make an appointment?" is an inappropriate communication technique referred to as using "Why" questions. While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation a. impedes further discussion. b. helps the nurse understand his or her own feelings in relation to the patient's verbal message. c. affects the nurse-physician relationship. d. helps the patient understand personal feelings in relation to his or her verbal message. -- ANSWER--d. helps the patient understand personal feelings in relation to his or her verbal message. Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient's personal feelings in relation to the patient's verbal message. The nurse-physician relationship is not the barrier to communication in this situation.
The use of euphemisms to avoid reality or to hide feelings is known as a. avoidance language. b. distancing language. c. sympathetic language. d. ethnocentric language. -- ANSWER--a. avoidance language. Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior. When addressing a toddler during the interview, the health care provider should a. use detailed explanations. b. ask the child, before the caregivers, about symptoms. c. use nonverbal communication. d. use short, simple, concrete sentences. -- ANSWER--d. use short, simple, concrete sentences. A toddler's communication is direct, concrete, literal, and set in the present. The healthcare provider should use short, simple sentences with concrete explanations. For a younger child such as a toddler, the parent will provide all or most of the history. Nonverbal communication
social affinity in which one person stands with another person, closely understanding his or her feelings. Parents or caregivers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms. a. 11 b. 7 c. 9 d. 5 -- ANSWER--b. 7 School-age children (starting at age 7) have the verbal ability to add important data to the history. The nurse should interview the parent and child together, but when a presenting symptom or sign exists, the nurse should ask the child about it first and then gather data from the parent. An example of an open-ended question or statement is a. "Tell me about your pain." b. "You are upset about the level of pain, right?" c. "On a scale of 1 to 10, how would you rate your pain?" d. "I can see that you are quite uncomfortable." -- ANSWER--a. "Tell me about your pain." Open-ended questions and statements ask for narrative information; they state the topic to be discussed but only in general terms. "Tell me about your pain" encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen. "On a scale of 1 to 10, how would you rate your pain?"; "I can see that you are quite uncomfortable"; and
"You are upset about the level of pain, right?" are closed or direct questions. Closed or direct questions and statements ask for specific information. This type of question or statement will elicit a short, one- or two-word answer, a yes or no response, or a forced choice. The most appropriate introduction to use to start an interview with an older adult patient is a. "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." b. "David, I am here to ask you questions about your illness; we want to determine what is wrong." c. "Because so many people have already asked you questions, I will just get the information from the chart." d. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" -
- ANSWER--a. "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." An older adult should be addressed by the last name; older adults may be offended by a younger person using their first names. The initial introduction should include the person's surname (unless a child) and the reason for the interview. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" is a closed-ended question. "Because so many people have already asked you questions, I will just get the information from the chart" does not allow for free expression of ideas. Which of the following is included in documenting a history source? a. Appearance, dress, and hygiene b. Documented relationship of support systems c. Reliability of informant
a. depression. b. excessive or uncontrollable drinking. c. unhealthy lifestyle behaviors. d. personal response to stress. -- ANSWER--b. excessive or uncontrollable drinking. CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. The "review of systems" in the health history is a. a short statement of general health status. b. an evaluation of past and present health state of each body system. c. a documentation of the problem as perceived by the patient. d. a record of objective findings. -- ANSWER--b. an evaluation of past and present health state of each body system. The purpose of the review of systems is to evaluate the past and present health state of each body system, to double check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. The reason for seeking care is a statement in the person s own words that describes the reason for the visit. This is typically known as a "chief complaint" or the reason for the health care visit. Objective data are the observations obtained by the health care professional during the physical examination. A short statement r/t
the patient's general health status is typically included in the complete physical assessment record. When recording information for the review of systems, the interviewer must document a. "negative" under the system heading. b. the presence or absence of all symptoms under the system heading. c. objective data that support the history of present illness. d. physical findings, such as skin appearance, to support historic data. -- ANSWER--b. the presence or absence of all symptoms under the system heading. When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms; otherwise, it is unknown which factors were asked. Recording physical findings in the review of systems are incorrect; the review of systems is limited to the patient's statements or subjective data. Writing "negative" after the system heading is also incorrect because it would be unknown which factors were asked. Recording objective data in the review of systems is incorrect; the review of systems is limited to the patient's statements or subjective data. Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include a. education, financial status, and value-belief system. b. family role, interpersonal relations, social support, and time spent alone. c. stressors, coping mechanisms, and change in past year. d. exercise and activity, leisure activities, and level of independence. -- ANSWER--a. education, financial status, and value-belief system.
