Chapter 1-4, 8-10

Question 1

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be

Answer 1

Objective Data

Question 2

A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:

Answer 2

Subjective Data

Question 3

The patients record, laboratory studies, objective data, and subjective data combine to form the:

Answer 3

Database

Question 4

Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as

Answer 4

Intuition

Question 5

piece of information, sign or symptom, piece of laboratory or imaging data

Answer 5

Cue

Question 6

tentative explanation for a cue or a set of cues that can be used as a basis for further investigation

Answer 6

hypothesis

Question 7

six steps of the nursing process (ADOPIE)

Answer 7

assessment, diagnosis, outcome identification, planning, implementation, evaluation

Question 8

What level of priority?

Those that are emergent, life threatening, and immediate, such as establishing, an airway or supporting breathing

Answer 8

First level priority problems

Question 9

What level of priority?
mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security

Answer 9

Second level priority problems

Question 10

What level of priority?

those that are important to the patient’s health but can be attended to after more urgent health problems are addressed.

Answer 10

Third level priority problems

Question 11

systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. More than best practice techniques

Answer 11

evidence based practice

Question 12

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?

a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress

Answer 12

D.

• ABC- airway, breathing, circulation

Question 13

Second-level priority problems include which of these aspects?

a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs

Answer 13

C.

Question 14

A critical thinking skill helps the nurse see relationships among the data

Answer 14

Clustering related cues

Question 15

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Answer 15

Breathing, pain, sleeping

Question 16

What step of the nursing process includes data collection by health history, physical examination, and interview?

Answer 16

Assessment

Question 17

What does the holistic health include?

Answer 17

Viewing the mind, body, and spirit as interdependent

Question 18

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?

a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individuals condition, and compare actual outcomes with expected outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.

Answer 18

C.

*After implementation, next do evaluation.

Question 19

learned from birth through language acquisition and socialization.

Answer 19

culture

Question 20

the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society

Answer 20

culture

Question 21

large groups of people with shared characteristics that are not common to all members of a culture.

Answer 21

subculture

Question 22

implies that the caregiver understands and attends to the total context of the individuals situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences

Answer 22

culturally competent

Question 23

implies that the caregiver possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting where they are practicing

Answer 23

culturally appropriate

Question 24

implies that caregiver possess some basic knowledge of and constructive attitudes towards the diverse cultural populations found in the setting in which they are practicing

Answer 24

culturally sensitive

Question 25

pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.

Answer 25

ethnicity

Question 26

process of adopting the culture and behavior of the majority culture

Answer 26

acculturation

Question 27

unidirectional, proceeding in a linear fashion from unacculturated to accultrated

Answer 27

assimilation

Question 28

dual pattern of identification

Answer 28

biculturalism

Question 29

mini database, small in scope; concerns mainly one problem, one cue complex, one body system

Answer 29

focused database

Question 30

What kind of database?
a patient with heart failure with the primary health care provider at regular intervals to reevaluate medications, identify changes in symptoms, and discuss coping strategies

Answer 30

follow up database

Question 31

health history and full physical examination

Answer 31

complete database

Question 32

Arises out of each persons unique life experience and his or her personal effort to find purpose in life.

Answer 32

spirituality

Question 33

What are the four processes of communication?

Answer 33

sending, receiving, internal factors, external factors

Question 34

What does sending include?

Answer 34

verbal and nonverbal communication, body language

Question 35

What does receiving include?

Answer 35

words and gestures must be interpreted in a specific context to have meaning. it attaches meaning determined by his or her experiences, culture, self-concept, and current physical and emotional states.

Question 36

what does internal factors include?

Answer 36

liking others, empathy, ability to listen, self awareness

Question 37

what does external factors include?

Answer 37

ensure privacy, refuse interruptions, physical environment, dress, note-taking, electronic health record

Question 38

asks for narrative information. states the topic to be discussed but only in general terms. for example: “tell me how I can help you.”

Answer 38

open-ended questions

Question 39

elicit a two word answer like yes or no

Answer 39

close or direct questions

Question 40

10 TRAPS of interviewing

Answer 40

1. providing false assurance or reassurance
2. giving unwanted advice
3. using authority
4. using avoidance language
5. distancing
6. using professional jargon
7. using leading or biased questions
8. talking too much
9. interrupting
10. using “WHY” questions

Question 41

what are the nonverbal skills? (7)

Answer 41

• physical appearance, posture, gestures, facial expression, eye contact, voice, touch

Question 42

Verbal Responses: Client’s perspective

Answer 42

• facilitation, silence, reflection, empathy, clarification

Question 43

Verbal Responses: Examiner’s perspective

Answer 43

• confrontation, interpretation, explanation, summary

Question 44

When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:

a. Ask someone who knows the patient well to help interpret this discrepancy.
b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors.
c. Try to integrate the verbal and nonverbal messages and then interpret them as an average.
d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

Answer 44

D.

**When nonverbal and verbal messages are congruent, the verbal message is reinforced.

Question 45

Define symptom:

Answer 45

subjective sensation that the person feels from the disorder

Question 46

define sign:

Answer 46

objective abnormality that you as the examiner could detect in a physical examination or through diagnostic testing

Question 47

Pain Scale:

Remember PQRSTU!

Answer 47

P- provocative or pallative
Q- quality or quantity
R- region or radiation
S- severity scale
T- timing
U- understand patient's perception of the problem

Question 48

Know the CAGE for alcoholics:

Answer 48

CUT
ANNOYED
GUILTY
EYE OPENER

Question 49

Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin?

a. Skin appears dry.
b. No lesions are obvious.
c. Patient denies any color change.
d. Lesion is noted on the lateral aspect of the right arm.

Answer 49

C.

Question 50

Assessment that includes ADL’s like: occupation, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, coping/stress management, environment, home safety hazards

Answer 50

Functional assessment

Question 51

What are the four techniques in the physical examination process? (in order)

Answer 51

inspection, palpation, percussion, auscultation

*IPPA (PP remember a before e)

Question 52

Palpation applies to what factors?

Answer 52

temperature, moisture, organ location and size, swelling, vibration/pulsation, rigidity/spasticity, presence of lumps/masses, tenderness/pain

** identify any tender areas and palpate them last

Question 53

Which technique is tapping the person’s skin with short, sharp strokes to assess underlying structures?

Answer 53

percussion

Question 54

Percussion includes:

Answer 54

• stationary hand, striking hand, and production of sound

Question 55

Palpation techniques include:

Answer 55

fingertips, fingers and thumb, dorsa of hands and fingers, base of fingers and ulnar surface of hand

Question 56

the use of this will block out extraneous room sounds

Answer 56

stethoscope

Question 57

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

a. Palpation
b. Inspection
c. Percussion
d. Auscultation

Answer 57

A

Question 58

Which part of the stethoscope is best use for high pitch sounds like breath, bowel, and normal heart sounds?

Answer 58

diaphragm (flat edge)

Question 59

When do you wash your hands?

Answer 59

• before and after every patient encounter
• after contact with blood/body fluids/secretions
• after contact with any alcohol based hand sanitizer (takes less time than hand washing with soap & water)
• after removing gloves

Question 60

What technique would the nurse listening to a sounds produced by the body, such as heart, blood vessels, lungs and abdomen?

Answer 60

auscultation

Question 61

funnels light into the ear and onto the tympanic membrane:

Answer 61

otoscope

Question 62

illuminates the internal eye structures

Answer 62

ophthalmoscope

Question 63

height appears within the normal range for age and genetic heritage

Answer 63

stature

Question 64

person stands comfortably erect as appropriate for age

Answer 64

posture

Question 65

body parts look equal bilaterally and are in relative proportion

Answer 65

symmetry

Question 66

person sits comfortably in chair or on bed or examining table, arms relaxed at sides, head turned to examiner

Answer 66

position

Question 67

How do you assess the pulse?

Answer 67

1. rate
2. rhythm
3. force
4. elasticity

Question 68

The nurse is performing a general survey. Which action is a component of the general survey?

a. Observing the patients body stature and nutritional status
b. Interpreting the subjective information the patient has reported
c. Measuring the patients temperature, pulse, respirations, and blood pressure
d. Observing specific body systems while performing the physical assessment

Answer 68

A.

Question 69

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:

a. Rapid measurement is useful for uncooperative younger children.
b. Using the TMT is the most accurate method for measuring body temperature in newborn infants.
c. Measuring temperature using the TMT is inexpensive.
d. Studies strongly support the use of the TMT in children under the age 6 years.

Answer 69

A.

**TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting.

Question 70

When assessing an older adult, which vital sign changes occur with aging?

a. Increase in pulse rate
b. Widened pulse pressure
c. Increase in body temperature
d. Decrease in diastolic blood pressure

Answer 70

B.

**With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure.

Question 71

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.

Answer 71

B.

**and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked.

Question 72

Which technique is correct when the nurse is assessing the radial pulse of a patient?

The pulse is counted for:

a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.

Answer 72

A.

**Recent research suggests that the 30-second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full minute.