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NUR 245 Exam 1
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The concept of health and healing has evolved in recent years. Which is the best description of health? a. health is the absence of disease b. health is a dynamic process toward optimal functioning c. health depends on an interaction of mind, body, and spirit within environment d. health is the prevention of disease - ANS-d. health is the prevention of disease Which would be included in the database for a new patient admission to a surgical unit? a. all subjective and objective data gathered by a health practitioner from a patient b. all objective data obtained from a patient through inspection, percussion, palpation, and auscultation c. a summary of a patients record, including laboratory studies d. all subjective and objective data gathered from a patient, and the results of any laboratory or diagnostic studies completed - ANS-d. all subjective and objective data gathered from a patient and the results of any laboratory or diagnostic studies completed You are reviewing assessment data of a 45-yr old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of: a. hypothetical reasoning b. diagnostic reasoning c. data. cluster
d. signs and symptoms - ANS-c. data cluster a patient is is the emergency department with nausea and vomiting. which would you include in the database? a. a complete health history and full physical exam b. diet and GI history c. previously identified problems d. start collection of data in conjunction with lifesaving measures - ANS-b. diet and GI history a patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond a. "it would be most efficient if you visit on an annual basis" b. "there is no recommendation for the frequency of health care visits." c. "your visits may vary, depending on your level of wellness." D. "You visits will be based on your preference." - ANS-c. "you visits may vary depending on your level of wellness." You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a. planning b. assessment c. implementation d. diagnosis - ANS-a. planning What does the nursing process ADPIE stand for? - ANS-A: assessment D: diagnosis P: planning I: implementation E: evaluation nursing process assesement - ANS-collect data: review clinical record health history physical exam functional assessment risk assessment review of the literature use evidence based techniques
c. competing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices d. finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds - ANS-a. combining clinical expertise with the use of nursing research to provide the best care for patients values and circumstances what can be determined when the nurse clusters data as part of the critical thinking process? a. this step identifies problems that may be urgent and require immediate action b. this step involves making assumptions in the data c. the nurse recognizes relevant information among the data d. risk factors can be determined so the nurse knows how to offer health teaching - ANS-c. the nurse recognizes relevant information among the data a patient says she is very nervous and nauseated and she feels as if she will vomit. this data would be what type? a. objective b. reflective c. subjective d. introspective - ANS-c. subjective the expert nurse differs from the novice nurse by acting without consciously thinking about the actions. this is referred to as: a. deductive reasoning b. intuition c. the nursing process d. focused assessment - ANS-b. intuition the ability to understand something immediately without the need for conscious reasoning which would be considered a risk diagnosis? a. identifying existing levels of wellness b. evaluating previous problems and goals c. identifying potential problems the patient may develop d. focusing on strengths and reflecting an individuals transition to higher levels of wellness - ANS-c. identifying potential problems the patient may develop which would be included in a holistic model of assessment? a. nursing goals for patient
b. anticipated growth and development patterns c. a patients perception of his or her own health d. the nurses perception of disease related to the patient - ANS-c. a patients perception of his or her own health the nurse uses health promotion activities with a new patient. what would this focus include? a. the nurse would try to change the patients perception of disease b.the nurse would search for identification of biomedical model interventions c. the nurse would help to identify negative health acts of the patient d. the nurse would empower the patient to choose a healthier lifestyle - ANS-d. the nurse would empower the patient to choose a healthier life style which is an example of objective data: a. patients history of allergies b. patients use of medications at home c. last menstrual period one month ago d. 2- x 5 -cm scar present on the right lower forearm - ANS-d. 2- x 5 -cm scar present on the right lower forearm during the evaluation phase of nursing process. which action would be included? a. validating the nursing diagnosis b. establsihing priorities related to patient care c. including the patient and family members d. establishing a timeline for planned outcomes - ANS-c. including the patient and family members Which statement best describes religion? a. an organized system of beliefs concerning the cause, nature, and purpose of the universe b. belief in a devine or superhuman spirit to be obeyed and worshiped c. affiliation with one of the 1200 recognized religions in the US d. the following of established rituals, especially in conjunction with health-seeking behaviors - ANS-a. an organized system of beliefs concerning the cause, nature, and purpose of the universe The major factor contributing to the need for cultural care nursing is: a. an increasing birth rate b. limited access to health care services c. demographic change
b. religion is charcterized by identification of a higher being shaping ones destiny; spirituality reflects an individuals perception of ones life having worth or meaning c. religion is the active interpretation of ones spirituality - ANS-b. religion is charcterized by identification of a higher being shaping ones destiny; spirituality reflects an individuals perception of ones life having worth or meaning The first step to cultural competency by nurses is to: a. identify the meaning of health to the patient b. understand how a healthcare delivery system works c. develop a frame of reference to traditional healthcare practices d. understand your own heritage and its basis in cultural values - ANS-d. understand your own heritage and its basis in cultural values which statement is true is regards to pain? a. nurses attitudes towards patient pain are unrelated to their own experiences with pain b. the cultural background of a patient is important in a nurses assessment of that patients pain c. a nurses area of clinical practice is most likely to determine his or her assessement of a patients pain d. a nurses years of clinical experience and current position are a strong indicator of his or her response to patient pain - ANS-b. the cultural background of a patient is important in a nurses assessment of that patients pain which factor is identified as a priority influence on a patients health status? a. poverty b. lifestyle factor c. legislative action d. occupational status - ANS-a. poverty which statement is most appropriate to use when initiating an assessment of cultural beleifs; with an older american indian patient: a. are you of the christian faith b. do you want to see a medicine man c. how often do you seek help from medical providers d. what cultural or spiritual beliefs are important to you? - ANS-d. what cultural or spiritual beliefs are important to you? ethnocentrism - ANS-tendency to view your own way of life as the most desirable, acceptable, or best and to act superior to another cultures way of life
which category is appropriate in a cultural assessment? a. family history b. chief complaint c. past medical history d. health-related beliefs - ANS-d. health-related beliefs which health belief practice is associated with patients who are of American Indian heritage? a. wearing bangle bracelets to ward off evil spirits b. believing that forces of nature must be kept in natural balance c. using swamp root as a traditional healer d. believing in shaman as a traditional healer - ANS-b. believing that forces of nature must be kept in natural balance which statement best reflects the magicoreligous causation of illness? a. each being is but a part of a larger structure in the world of nature as it related to health and illness b. causality relationships exists, leading to expression of illness c. belief in the struggle between good and evil is reflected in the regulation of health and illness d. illness occurs as a result of disturbances between hot and cold reactions - ANS-c. belief in the struggle between good and evil is reflected in the regulation of health and illness The practioner, entering the exam room to meet a patient for the first time, states "Hello, I'm M.M and im here to gather some infromation from you and to perform your examination. This will take about 30 minutes. D.D is a student working with me. If its alright with you she will remain during the examination. which of the following must be added to cover all aspects of the interview contract? a. a statement regarding confidentiality, patient costs, and the expectations of each person b. the purpose of the interview and the role of the interviewer c. time and place of the interview and confidentiality statement d. an explicit purpose of the interview and description of the physical exam, including diagnostic testing - ANS-a. a statement regarding confidentiality, patient costs, and the expectations of each person
a. a daughter who is taking her older father home to live with her b. an older patient who lives alone c. a wife who has cared for her husband for the past 4 yrs at home d. a son whose parents live in an associated living facility - ANS-c. a wife who has cared for her husband for the past 4 yrs at home Which is an example of an informal social support network for the aging adult : a. a neighbor who drops by with newspapers and magazines on a regular basis b. an area church that offers a weekly acitivity and luncheon for sneniors in the neighborhood c. a home health care agency that provides weekly blood pressure screenings at the church luncheon d. a senior ciitizen chess club whos members hold classes at the local boys club - ANS-a. a neighbor who drops by with newspapers and magazines on a regular basis when completing a spiritual assessment you should: a. use yes and no questions as the foundation for future dialogue b. use open-ended questions to help the patient understand potential coping mechanisms c. try to complete this assessment as soon as possible after meeting the patient d. wait until a member of the clergy can be involved in the assessment - ANS-b. use open-ended questions to help the patient understand potential coping mechanisms when you preform a functional assessment of an older patient, which is most appropriate? a. observe the patients ability to perform other tasks b. ask the patients partner how he or she does when preforming tasks c. review the medical record for information on the patients abilities d. ask the patients physician for infromation on the patients abilites - ANS-a. observe the patients ability to perform other tasks an older adults advance activities of daily living would include: a. recreational activities b. meal prep c. balancing the checkbook d. self-grooming activities - ANS-a. recreational activities when using the various instruments to assess an older persons ADLs remember that a disadvantage of these instruments includes: a. the reliability of the tools
b. self or proxy report of functional activities c. lack of confidentiality during the assessment d. insufficient detail about the deficinecies indentified - ANS-b. self or proxy report of functional activities inspection - ANS-begins when you first meet the person with a general survey palpation - ANS-applies sense of touch to assess texture, temp. moisture, organ location and size, swelling/vibration, regidity, crepation, presence of lumps or masses avoid any situation where palpation could cause internal injury or pain percussion - ANS-tapping persons skin with short, sharp stroke to assess underlying structures direct: striking hand directly contacts body wall indirect: using both hands the striking hand contacts stationary hand fixed on persons skin auscultation - ANS-listening to sounds of the body using stethoscope Health literacy - ANS-understanding and following directions that lead to effective communication between the patient and the healthcare provider neuropathic pain - ANS-abnormal processing of pain message types: diabetes, herpes, shingles, HIV/AIDs etc. visceral pain - ANS-originates from larger interior organs ex. kidney or stomach deep somatic pain - ANS-comes from sources such as blood vessels, joints, tendons, muscles, and bone cutaneous pain - ANS-derived from skin surface and subcutaneous tissues; injury is superficial with sharp, burning sensation
b. proceed with the interview patients are usually truthful with a health care practicioner c. make a mental note to discuss the behavior after the physical examination d. proceed with interview and exam as outlined on the agency assessment form. the patients behavior is appropriate for the circumstances - ANS-a. use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patients attention for what or with whom should touch be used during the interview? a. only with an individual from a western culture b. as a routine way of establishing contact with the person and communicating empathy c. only with patients of the same gender d. only if the interviewer knows the person well - ANS-d. only if the interviewer knows the person well children usually come for healthcare with caregiver. at about what age should the interviewer begin to question the child regarding presenting symptoms? a. 5 yrs b. 7 yrs c. 9 yrs d. 11 yrs - ANS-b. 7yrs because of adolescents developmental level, not all interviewing techniques can be used with them. which techniques should be avoided? a. facilitation and clarification b. confrontation and explanation c. empathy and interpretations d. silence and reflection - ANS-d. silence and reflection knowledge of the use of personal space is helpful for the health care provider. personal distance is generally considered to be: a. 0- 1/2 ft b. 1 1/2 - 4 ft c. 4 -1 ft d. 12 or more ft - ANS-b. 1 1/2 - 4 ft Mr. B tells you, "everyone here ignores me." you respond "ignores you?" this technique is best described as: a. clarification b. selective listening c. reflecting
d. validation - ANS-c. reflecting what does active listening NOT include? a. taking detailed notes during the interview b. watching for clues in body language c. repeating statements back to the person to make sure you have understood d. asking open-ended questions to explore the persons perspective - ANS-a. taking detailed notes during the interview when interviewing a patient who does not speak english, the examiner should: a. take advantage of family members who are readily avail and willing to assist b. use a qualifies medical interpreter who is culturally literate c. seek as much information as possible and then continue with the examination d. wait until a qualified medical interpreter is available before starting the interview - ANS-b. use a qualifies medical interpreter who is culturally literate with older adults, how should the examiner proceed with the interview: a. proceed in more organized and concise manner b. consider the fatigue of the older person and break the interview into shorter segments c. ask a family member to complete some of the records while moving ahead with the interview d. raise you voice if the patient does not appear to hear you - ANS-b. consider the fatigue of the older person and break the interview into shorter segments when reading a medical record you see the following notation: Patient states :I have has a cold for about a week and now I am having difficulty breathing." this is an example of: a. past health history b. a review of systems c. a functional assessment d. a reason for seeking care - ANS-d. a reason for seeking care functional assessment: - ANS-measures a person's self care ability in the areas of general physical health; ADLs such as bathing, dressing, toileting, eating, walking ; instrumental ADLs housekeeping, cooking, laundry etc. you have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is: a. rephrase the same questions later in the interview
The impact of child adoption on the daily activities of a child is referred to as: a. developmental history b. instrumental activities of daily living c. reason for seeking care d. interpersonal relationship assessment - ANS-d. interpersonal relationship assessment Which two sections of the child's health history become separate sections because of their importance to the child's current health status? a. Play activities and rest patterns b. prenatal and postnatal status c. developmental and nutritional status d. accidents, injuries,. and immunizations - ANS-c. developmental and nutritional status Purpose of a health history: - ANS-to provide a database of subjective information about the patients past and present health While assessing a man for allergies he states he is allergic to penicillin. which response is best? a. are you allergic to any other drugs? b. how often have you received penicillin? c. ill write you allergy on your chart so you wont receive any. d. please describe what happens to you when you take penicillin - ANS-d. please describe what happens to you when you take penicillin 4 main headings of the mental status assessment A-B-C-T: - ANS-appearance, behavior, cognition, thought process Select the finding that most accurately describes appearance of a patient: a. tense posture and restless activity. clothing clean but not appropriate for season (t- shirt and shorts in cold weather) b. oriented x 3. affect appropriate for circumstances c. alert and responds to verbal stimuli. tearful when diagnosis is discussed d. laughing innapropriatley. oriented x 3 - ANS-b. oriented x 3. affect appropriate for circumstances oriented x 4: - ANS-person is alert and oriented to person, place, time and event Objective data appearance: - ANS-posture- erect and position is relaxed body movements are voluntary, coordinated and smooth
dress is appropriate for setting, season, age, gender grooming and hygiene is congruent with age objective data: cognitive function - ANS-attention span recent memory : assess in interview by 24 hr recall remote memory: in the context of interview ask person about verifiable past events Mini Cog test: - ANS-tests persons executive function including ability to plan, manage time, organize activities, and working memory You are assessing short-term cognitive memory. Which assessment shows the ability to lay down new memories? a. noting wether the patient completes a thought without wandering b. a test of general knowledge c. a description of past medical history d. use of four unrelated words test - ANS-d. use of four unrelated words test aphasia - ANS-loss of ability to speak or write coherently or to understand speach or writing due to a cerebrovascular accident working with patients with aphasia use word comprehension, reading, and writing You are preparing the discharge plan for a patient with aphasia. What assessment should you include in the plan? a. ask the patient to calculate serial 7s b. ask the patient to name their grandchildren and their birthdays c. ask patient to demonstrate word comprehension by naming articles in room or on body as you point to them d. ask the patient to interpret proverb - ANS-c. ask patient to demonstrate word comprehension by naming articles in room or on body as you point to them On a patients second day in an acute care hospital the patient complains about the "bugs" on the bed. The bed is clean. this would be an example of altered: a. thought processes b. orientation c. perception d. recent memory - ANS-c. perception one way to assess cognitive function and to screen dementia is with: a. the proverb interpretation test
c. it may take him a little longer to respond but his general knowledge and abilities should not have declined d. he will have had decrease in his response time due to language loss and a decrease in general knowledge - ANS-c. it may take him a little longer to respond but his general knowledge and abilities should not have declined when assessing mental status in children, what statement is true? a. all aspects of mental status in children are interrelated b. children are highly labile and unstable until the age of 2 c. childrens mental status is largely a function of their parents level of functioning until the age of 7 d. a childs mental status is impossible to asses until the child develops the ability to concentrate - ANS-a. all aspects of mental status in children are interrelated glasgow Coma scale: - ANS-useful in testing conciousness in an aging person whom confusion is common during an initial home visit the patients temperature was noted to be 97 degree F. How would you interpret this? a. it cannot be evaluated without knowledge of persons age b. it is below normal, the person should be assessed for possible hypothermia c. it should be retaken by the rectal route, because it best reflects core body temp d. it should be revalauted at the next visit before decision is made - ANS-a. it cannot be evaluated without knowledge of persons age select the best description of an accurate assessment of a patients pulse. a. count for 15 seconds if the pulse is regular b. begin counting with zero; count for 30 seconds c. count for 30 seconds and multiply by 2 for all cases d. count for 1 full minute; begin counting with 0 - ANS-c. count for 30 seconds and multiply by 2 for all cases After assessing the patients pulse the practioner determines it to be normal. this would be recorded as: a. 3 + b. 2 + c. 1 + d. 0 - ANS-b. 2 + Pulse pressure: - ANS-difference between the systolic and diastolic pressure
mean artierial pressure: - ANS-diastolic pressure plus one third of the pulse pressure Why is it important to match the appropriate size blood pressure cuff to the persons arm and shape not to the persons age? - ANS-using a cuff that is too narrow will give a falsely high reading a patient is being seen in the clinic for complaints of "fainting episodes that started last week" how should you proceed with the examination? a. take the blood pressure in both arms and thighs b. ask the person to walk a few paces and then take the blood pressure c. record the blood pressure in the lying, sitting, and standing positions d. record the blood pressure in the lying and sitting positions and average these numbers to obtain the mean. blood pressure - ANS-c. record the blood pressure in the lying, sitting, and standing positions The nurse is conducting a health fair for older adults. which statement is true regarding vital sign measurements in aging adults? a. the pulse is more difficult to palpate because of the stiffness of the blood vessels b. an increased respiratory rate and shallower inspiratory phase are possible findings c. a decreased pulse pressure occurs from changes in systolic and diastolic pressure - ANS-b. an increased respiratory rate and shallower inspiratory phase are possible findings at which phase does the patient become aware of a painful sensation? a, modulation b. transduction c. perception d. transmission - ANS-c. perception while taking a history, the patient describes a burning painful sensation that moves around the toes and bottoms of the feet. these symptoms suggest: a. nociceptive pain b. neuropathic pain c. visceral pain d. muscular pain - ANS-b. nueropathic pain An appopriate tool to assess an individuals instrumental activities of daily living is a tool by: a. Katz
