ch 6 Recognize Cues from Assessment Data

Question 1

To effectively recognize patient cues, which concepts would the nurse need to understand?
- Nonverbal cues are less significant than verbal cues.
- The first few minutes of the patient encounter are critical.
- A nonjudgmental environment promotes communication.
- The nurse should prevent moments of silence during the patient interview.
- The nurse should adapt the physical assessment based on patient age.

Answer 1

• The first few minutes of the patient encounter are critical.
• A nonjudgmental environment promotes communication.
• The nurse should adapt the physical assessment based on patient age.

Question 2

Which factors can hinder the nurse’s ability to recognize patient cues?
- The patient is 3 years old.
- The patient is crying uncontrollably.
- The patient does not speak English as a first language.
- The patient’s culture discourages eye contact with strangers.
- The patient response is repeated by the nurse.

Answer 2

• The patient is 3 years old.
• The patient is crying uncontrollably.
• The patient does not speak English as a first language.
• The patient’s culture discourages eye contact with strangers.

Question 3

Which examples are objective patient cues collected from the electronic health record?
- Potassium level is 3.5 mmol/L.
- Blood pressure is 118/70 mm Hg.
- Patient reports tactile fever.
- Heart rate is 72 beats/min.
- Bowel sounds are heard in all quadrants.

Answer 3

• Potassium level is 3.5 mmol/L.
• Blood pressure is 118/70 mm Hg.
• Heart rate is 72 beats/min.
• Bowel sounds are heard in all quadrants.

Question 4

Which factor can influence the nurse’s ability to recognize and categorize patient cues?
- The patient’s personal beliefs
- Experience with other patients
- Evaluation of patient outcomes
- Development of the plan of care

Answer 4

Experience with other patients

Question 5

The answer to which question would help the nurse categorize patient cues according to the degree of concern?
- Which information is relevant?
- Which patient data are most important?
- Which cues demand immediate attention?
- Which information is connected to the patient issue?

Answer 5

Which cues demand immediate attention?

Question 6

Which patient cue would the nurse categorize as “urgent” for a patient diagnosed with pneumonia?
- Shortness of breath
- Elevated temperature
- Auscultation of coarse crackles
- Oxygen saturation level of 95% on 2 L oxygen

Answer 6

Shortness of breath

Question 7

Which patient cue would the nurse categorize as “important” for a patient diagnosed with a femur fracture?
- Gender
- Temperature of 102.4°F (39°C)
- Pain rating of 2 on a scale of 0 to 10
- Oxygen saturation level of 89% on room air

Answer 7

Temperature of 102.4°F (39°C)