Potter Perry Fundamentals of Nursing I CH 15,16,17,18,19,20 Questions) and Verified Answer, Exams of Nursing

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15,16,17,18,19,20 Questions) and Verified

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-address the client with the appropriate title and her last name -use a mix of open-ended and close-ended questions -perform the general survey before the examination - CORRECT ANSWERS A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? -posture -skin lesions -speech - CORRECT ANSWERS A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? auscultation - CORRECT ANSWERS A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? -plan to allow plenty of time for position changes -make sure the client has any essential sensory aids in place -tell the client to take her time answering questions -invite the client to use the bathroom before beginning the examination - CORRECT ANSWERS A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? dorsal surface - CORRECT ANSWERS A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature?

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basic - CORRECT ANSWERS A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food". The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? responsibility - CORRECT ANSWERS A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and call the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? -the client is nonadherent with coughing, deep breathing, and dangling -the client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr -the client's vital sings are heart rate 110/min, respiratory rate 20/min, temperature 98.6 F, and blood pressure 136/80 mm Hg - CORRECT ANSWERS A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the client's pan management is inadequate. Which of the following data reinforce this suspicion? knowledge - CORRECT ANSWERS A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? discipline - CORRECT ANSWERS A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?

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reassess the client to determine the reasons for inadequate pain relief - CORRECT ANSWERS By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing practice? assessment - CORRECT ANSWERS A newly licensed nurse is reporting to the charge nurse about the are she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hrs PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? -respiratory rate is 22/min with even, unlabored respirations -skin is pink, warm, and dry -the assistive personnel reports the client walked with a limp - CORRECT ANSWERS A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? -showing a client how to use progressive muscle relaxation -performing a daily bath after the evening meal -repositioning a client every 2 hr to reduce pressure ulcer risk - CORRECT ANSWERS A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the nurse include? "I will determine the most important client problems that we should address." - CORRECT ANSWERS A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?

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Participate in a unit meeting to discuss feelings about the patient deaths - CORRECT ANSWERS Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress? Applying ethical criteria. - CORRECT ANSWERS A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: Basic critical thinking. - CORRECT ANSWERS A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: responsible - CORRECT ANSWERS A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude: discipline (2) - CORRECT ANSWERS By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude? reflection - CORRECT ANSWERS A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called:

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identify the problem collect data formulate a question or hypothesis test the question or hypothesis evaluate results of the study - CORRECT ANSWERS Place the steps of the scientific method in their correct order with number 1 being the first step of the process. Spending time establishing relationships with patients - CORRECT ANSWERS An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient? diagnostic reasoning - CORRECT ANSWERS A nurse enters a 72-year-old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of: truth seeking - CORRECT ANSWERS Be objective in asking questions of a patient. open-mindedness - CORRECT ANSWERS Be tolerant of the patient's views and beliefs analyticity - CORRECT ANSWERS Anticipate how a patient might respond to a treatment.

15,16,17,18,19,20 Questions) and Verified

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Systematicity - CORRECT ANSWERS Organize assessment on the basis of patient priorities. Consider availability of assistive personnel to obtain the specimen Combine activities to resolve more than one patient problem Analyze the diagnoses/problems and decide which are most urgent based onexx patients' needs - CORRECT ANSWERS A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? experience complex critical thinking - CORRECT ANSWERS A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? Initiative in reading current evidence from the literature Application of nursing theory Considering holistic view of patient needs - CORRECT ANSWERS Which of the following describes a nurse's application of a specific knowledge base during critical thinking? The nurse thinks back about a personal experience before administering a medication subcutaneously.

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The nurse uses a pain-rating scale to measure a patient's pain. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. - CORRECT ANSWERS In which of the following examples is a nurse applying critical thinking skills in practice? Health perception-health management pattern - CORRECT ANSWERS A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? Clinical inference. - CORRECT ANSWERS The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: A problem-oriented approach - CORRECT ANSWERS A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? Working phase - CORRECT ANSWERS The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? "You have four children; do you have any concerns about going home and caring for them?" - CORRECT ANSWERS A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of

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a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? Open-ended - CORRECT ANSWERS Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? Patient's level of function. - CORRECT ANSWERS A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: Self-perception-self-concept pattern - CORRECT ANSWERS A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." "Tell me what brought you to the hospital." "You say you've lost weight. Tell me how much weight you've lost in the last month." "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?" "I have no further questions. Thank you for your patience." - CORRECT ANSWERS A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. Tell me what makes your headaches begin. - CORRECT ANSWERS During a visit to the clinic, a patient tells the nurse that he has been having headaches on

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and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? Collection of information from patient's family members Recognition that further observations are needed to clarify information Comparison of data with another source to determine data accuracy - CORRECT ANSWERS Which of the following examples are steps of nursing assessment? An observation of how a patient turns and moves in bed The care recommendations of a physical therapist The results of a diagnostic x-ray film - CORRECT ANSWERS When a nurse conducts an assessment, data about a patient often comes from which of the following sources? The skin around the wound is tender to touch Patient has drainage from surgical wound. Body temperature is 38.3° C (101° F). - CORRECT ANSWERS A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? The nurse asks the patient to rate his pain on a scale of 0 to 10. The nurse assesses the patient's lower-limb strength. - CORRECT ANSWERS A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? Listen attentively to the patient's story.

15,16,17,18,19,20 Questions) and Verified

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Use gestures that reinforce your questions or comments. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue. - CORRECT ANSWERS The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult?