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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 used to follow up on short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. 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. A nurse precepting a student nurse asks, "What's the most important step in the critical- thinking 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. Follow-up - ANSWER-b. Complete
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. 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 used to follow up on short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. An emergency database includes a rapid collection of data often obtained concurrently with lifesaving measures. Which of the following is an example of objective data? a. A sore throat b. An earache c. Alert and oriented
d. Dizziness - ANSWER-c. Alert and oriented
Objective data is what the health professional observes; level of consciousness and orientation are observations. Subjective data is what the person says about himself or herself during history taking. Which of the following is an example of subjective data? a. Blood glucose 126 md/dL b. Pain rated at 7 out of 10 c. Heart rate of 76 bpm
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.
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. An example of objective data is a. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion. b. a complaint of left knee pain. c. crepitation in the left knee joint.
d. left knee has been swollen and hot for the past 3 days. - ANSWER-c. crepitation in
the left knee joint. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation. Subjective data is what the person says about himself or herself during history taking. While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following would most likely describe this patient's view of wellness? a. The phlegm will be replaced with dryness. b. The humors must be balanced. c. Good is hot.
d. Evil is hot. - ANSWER-b. The humors must be balanced.
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. 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.
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.
e. the heritage of the patient. - ANSWER-a, c, d, e
Discrete areas of knowledge for cultural competence include understanding of one's own heritage, the heritage of the nursing profession, the heritage of the patient, and the heritage of the health care system. Understanding cultural and ethnic values is not an area of knowledge for cultural competence. When preparing the physical setting for an interview, the interviewer should a. stand next to the patient to convey a professional demeanor. b. conduct the interview at eye level and at a distance of 4 to 5 feet. c. reduce noise by turning the volume on the television or radio down.
d. set the room temperature between 64° F and 66° F. - ANSWER-b. conduct the
interview at eye level and at a distance of 4 to 5 feet. Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet. The room temperature should be set at a comfortable level; a temperature between 64° F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment to reduce noise. The interviewer and the patient should be comfortably seated; standing communicates haste and assumes superiority. Which of the following statements made by the interviewer would be an appropriate response? a. "Tell me what you mean by 'bad blood.'" b. "If I were you, I would have the surgery." 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.
professional communication. Older adults may need special considerations r/t physical limitations (e.g., adjusted pace to avoid fatigue, impaired hearing). Viewing the world from another person's inner frame of reference is called a. empathy. b. clarification. c. reflection
d. sympathy - ANSWER-a. empathy.
Empathy means viewing the world from the other person's inner frame of reference. Reflection is repeating part of what the person has just said. Clarification is used to summarize the person's words or to simplify the words to make them clearer. Sympathy is a 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
d. Cognition and literacy level - ANSWER-c. Reliability of informant
The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history. A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about a. the patient's perception of pain. b. the nature or character of the headache. c. relieving factors.
d. aggravating factors. - ANSWER-d. aggravating factors.
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. Functional assessment measures a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. These areas are r/t the activity and exercise section of the functional assessment. These areas are r/t the interpersonal relationships and resources section of the functional assessment. These areas are r/t the coping and stress management section of the functional assessment. PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to a. the ability to perform activities of daily living (ADLs). b. substance use and abuse. c. pain presentation.
d. severity of dementia. - ANSWER-c. pain presentation.
The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory- Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person's self-care ability including the ability to perform ADLs. The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to a. ask the patient if there is someone who could verify information.
b. rephrase the same questions later in the interview. c. call a family member to confirm information.
d. review previous medical records. - ANSWER-b. rephrase the same questions later
in the interview. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corroboration of information from another individual is not within the context of the present interview. This would occur outside the context of the interview. When taking a health history from an adolescent, the interviewer should a. ask every youth about the use of condoms. b. have at least one parent present during the interview. c. ask about violence and abuse before asking about alcohol and drug use.
d. interview the youth alone with a parent in the waiting area. - ANSWER-d. interview
the youth alone with a parent in the waiting area. The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (r/t injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and What information is included in greater detail when taking a health history on an infant? a. Environmental hazards b. History of present illness c. Nutritional data
d. Family history - ANSWER-c. Nutritional data
The amount of nutritional information needed depends on the child's age; the younger the child is, the more detailed and specific the data should be. The health history is adapted to include information specific for the age and developmental stage of the child (e.g., mother's health during pregnancy, labor, and delivery and the perinatal period). The developmental history and nutritional data are important for current health of infants and children. Dehydration and malnutrition can be manifestations of ________________ in older adults. a. physical abuse b. intimate partner violence
abuse. A family genogram is not as important as the mental status examination, skin assessment, and history. It is also important to assess and document prior abuse, including intimate partner violence, physical and sexual abuse, and rapes of all kinds. The skin assessment is also an important part of the history and examination. The health care system may help abused women by a. providing financial and supportive services. b. estimating the ages of bruises. c. providing shelter from the abusive individual.
d. identifying abuse in the early stages. - ANSWER-d. identifying abuse in the early
stages. The health care system can be an extremely important early point of contact. Uncovering abuse in early stages may stop the pattern of violence and avoid or minimize long-term health problems. The health care system does not provide shelter for abused women. The health care system does not provide financial assistance or supportive services for abused women. Estimation of the age of bruises should be avoided because evidence does not support the ability to date a bruise. Abused women have been found to have significantly more health problems, including a. cardiovascular disease. b. chronic anemia. c. chronic pain.
d. cancer. - ANSWER-c. chronic pain.
Abused women have been found to have significantly more injuries. Also, abused women have more chronic health problems including neurologic, gastrointestinal, and gynecologic symptoms and chronic pain. Abused women do not have a higher incidence of cardiovascular disease. Abused women do not have a higher incidence of cancer. Abused women do not have a higher incidence of chronic anemia. The nurse caring for an older adult suspects older adult abuse. Which action is appropriate? a. Confront the caregivers about the suspicion of abuse. b. Collect proof of abuse before notifying the authorities. c. Report the abuse if the older adult gives permission.
d. Notify the authorities of the suspected older adult abuse. - ANSWER-d. Notify the
authorities of the suspected older adult abuse. The nurse is a mandatory reporter of older adult abuse and should notify the authorities of suspected older adult abuse. The nurse does not need proof of abuse before calling the authorities. The nurse should not confront the caregivers if older adult abuse is
suspected. The nurse does not need permission from the older adult before calling the authorities. The nurse is assessing a person who is a suspected victim of abuse. When documenting assessment data, which of the following is the most important concept for the nurse to remember? (Select all that apply.) a. Words used when documenting should be sanitized. b. It must be detailed and unbiased. c. Speculation on the cause of injury should be included. d. Use the exact terms the abused person uses to describe sexual organs.
e. Quotation marks should be used for severe threats of harm. - ANSWER-b, d, e
Documentation should be non-biased and include specific details, especially when documenting signs of physical abuse. Measurements, color, and other characteristics are important to document as specifically as possible and should include photographic documentation. Verbatim documentation of reported perpetrator's threats can be useful in future court proceedings. Using exact terms and asking for clarification if the nurse is unsure what the person means is important. When quoting or paraphrasing what the abused person has said, do not sanitize the words. The nurse should never speculate regarding the cause of signs/symptoms. Every time the nurse documents health assessment data, he/she must only document what they hear or assess through inspection, palpation, percussion, and auscultation. Opinions or information not specific to assessment findings should never be included in documentation. A woman seeks medical attention for a cut made by a knife during a physical assault. The health care provider would document the cut as an a. incision. b. ecchymosis. c. avulsion.
d. abrasion. - ANSWER-a. incision.
An incision is a cut or wound made by a sharp instrument. Ecchymosis is a hemorrhagic spot or blotch in the skin or mucous membrane that forms a non-elevated, rounded or regular, blue or purplish patch. An avulsion is the tearing away of a structure or part. An abrasion is a wound caused by rubbing the skin or mucous membrane. To examine a toddler, the nurse should a. allow the child to sit on the parent's lap. b. ask the child to decide whether parents or siblings should be present. c. remove the child's clothing at the beginning of the examination.
d. perform the assessment from head to toes. - ANSWER-a. allow the child to sit on
the parent's lap.
a. back of the hands and fingers. b. fingertips. c. base of the fingers.
d. opposition of the fingers and thumb. - ANSWER-b. fingertips.
The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration. An ophthalmoscopic examination is an examination of the a. pharynx. b. nasal turbinates. c. inner ear.
d. internal structures of the eye. - ANSWER-d. internal structures of the eye.
An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares. Which of the following is considered when preparing to examine an older adult? a. Avoid physical touch to avoid making the older adult uncomfortable. b. Confusion is a normal, expected finding in an older adult. c. Be aware that loss will result in poor coping mechanisms.
d. Base the pace of the examination on the patient's needs and abilities. - ANSWER-d.
Base the pace of the examination on the patient's needs and abilities. The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging. When performing percussion, the examiner a. taps fingertips over bony processes. b. strikes the stationary finger at the distal interphalangeal joint. c. strikes the flank area with the palm of the hand.
d. strikes the stationary finger at the proximal interphalangeal joint. - ANSWER-b.
strikes the stationary finger at the distal interphalangeal joint. To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed). At the end of the examination, the examiner should a. compare objective and subjective data for discrepancies. b. have findings confirmed by another provider. c. review the findings with the patient.
d. complete documentation before leaving the examination room. - ANSWER-c. review
the findings with the patient. At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination. The examiner should use hand-washing instead of an alcohol-based hand rub a. if the patient is HIV positive. b. if the patient has an infection with Clostridium difficile. c. if the patient has an infection with Mycobacterium tuberculosis.
d. if the patient has an infection with hepatitis B virus. - ANSWER-b. if the patient has
an infection with Clostridium difficile. The examiner should use the mechanical action of soap-and-water hand-washing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV. The nurse documents the following findings for the behavioral portion of the general survey assessment, "patient demonstrates flat affect, lack of eye contact, hair not brushed, and strong body odor". The nurse should be concerned that the patient is which of the following? a. Depression b. Bulimia c. Dysarthria
d. Seizures - ANSWER-a. Depression
