Chapter 1-4 book info

Question 1

Safety alert: all future care is based on the HA, so its extremely important that HA data are complete and accurate. This is one of the most important skills that you’ll use as a nurse

Question 2

Safety alert:
All life threatening probs identified during the initial assessment require the initiation of critical interventions

Answer 2

• assisst w circulation
• open pts airway
• assist pt breathing
• protect cervical spine if injured
• ensure disoriented or suicidal pt is safe
• provide pain management and sedation

Question 3

A pt is having adverse effects resulting from a med. The nurse calls the primary care provider to request a change in the med order. The nurse is functioning as a
1. educator
2.advocate
3. organizer
4. counselor

Answer 3

2. advocator

Question 4

Nurses advocate for underserved populations to reduce health disparities. This promotes
1. autonomy
2. altruism
3. respect
4.human dignity

Answer 4

3. respect

Question 5

Nurses belong to the ANA as part of their
A. ongoing professional responsibility.
B. role as manager of care.
C. wellness promotion for patients.
D. cultural education activities.

Answer 5

A

Question 6

The purpose of health assessment is to
A. obtain subjective and objective data.
B. intervene to correct difficulties.
C. outline appropriate care.
D. determine whether interventions are effective.

Answer 6

A

Question 7

The nurse documents the following information in a patient’s chart: “Cough and deep breathe every hour while awake.” This is an example of
A. evidence-based nursing.
B. priority setting.
C. comprehensive assessment.
D, nursing interventions.

Answer 7

D

Question 8

The nurse provides teaching about smoking cessation to a 20 year-old patient. The nurse asseses that the patient is concerned because their father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient?
A. Health belief model
B. Diagnostic reasoning model
C. Cultural competence model
D. Body systems model

Answer 8

A

Question 9

7. Which of the following processes is the most important when providing nursing care to a patient who is ill?
   A. Writing outcomes
   B. Performing a focused assessment
   C. Collecting objective data
   D. Using clinical judgment.

Answer 9

D

Question 10

8. A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform on admission?
   A. Emergency
   B. Focused
   C. Comprehensive
   D. Illness

Answer 10

C

Question 11

9. Which of the following are the components of a comprehensive health assessment?
   A. Nursing diagnoses
   B. Goals and outcomes
   C. Collaborative problems
   D. Examination of body systems

Answer 11

D

Question 12

10. The nurse conducts the health history based on the patient’s responses to the medical diagnosis.
    This type of framework is based on the
    A. functional framework.
    B. objective framework.
    C. coordinator framework.
    D. collaborative framework.

Answer 12

A

Question 13

SAFETY ALERT
If talking about a situation seems to increase rather than defuse a patient’s anger, you may redirect the interview.
If a patient is abusive or overly aggressive, it may be necessary to take a time-out by saying, “I understand that you’re very angry right now. I am feeling a little concerned/ uncomfortable/unsafe, so I can either have someone else come in to talk with you or come back in 15 minutes. Which would you prefer?” Also be aware of personal space, and if the patient becomes physically aggressive, leave the area so you will not be harmed.

Question 14

3. The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is
   A. “Don’t cry. It will be OK.”
   B. “My mother has the same thing.”
   C. “I think that you should have surgery.”
   D. “I’ll stay with you” (gets a tissue).

Answer 14

D

Question 14

SAFETY ALERT
If an interview reveals confidential material, disclose those things required to be reported by law, such as suicidal thoughts, violence at home, or rape. Inform the patient at the beginning of the interview that you must report harm to self or others to get needed assistance. You should notify authorities only after ensuring the victim’s safety.

Question 15

1. A patient says that they are having throbbing pain that they rate as 6 on a 10-point scale. This is referred to as
   A. subjective primary data.
   B. subjective secondary data.
   C. objective primary data.
   D. objective secondary data.

Answer 15

A

Question 15

2. The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the
   A. preinteraction phase.
   B. beginning phase.
   C working phase.
   D. closing phase.

Answer 15

C

Question 16

5. The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is
   A. “You must be extremely worried.”
   B. “I’d be in worse shape than you are if it were my baby.”
   C. “Is there anyone here that you can talk to?”
   D.”You seem worried, but I need to ask a few questions.”

Answer 16

D

Question 16

4. When gathering the family history, the nurse draws a genogram
   A. using circles for males and squares for females.
   B. putting the patient on the left to show birth order.
   C. inserting lines between parents to show marriage.
   D. listing health problems above the symbol for the patient.

Answer 16

C

Question 17

6. The nurse asks, “What are the most important things to you in life?” to assess the functional pattern related to
   A. role.
   B. self-perception.
   C. coping.
   D. values.

Answer 17

D

Question 18

7. To assess self-perception, the nurse asks
   A.”How would you describe yourself?”
   B. “Are you having difficulty handling any family problems?”
   C.”What gives you hope when times are troubled?”
   D. “How do you usually deal with stress? Is it effective?”

Answer 18

A

Question 19

8. The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing
   A. whether the patient is a reliable historian.
   B. functional health patterns.
   C. ADLS.
   D. review of systems.

Answer 19

C

Question 20

10. The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking
    A. uses subjective data to analyze findings and intervene.
    B. documents and communicates data using appropriate medical terminologies.
    C. individualizes health assessment considering the age, gender, and culture of the patient.
    D. uses assessment findings to identify medical and nursing diagnoses.

Answer 20

A

Question 20

9. The nurse assessing an older adult focuses the health history on
   A. previous pregnancies, obstetric history, and psychosocial factors.
   B. birth history, immunizations, and growth and development.
   C. sensory deficits, illness history, and lifestyle factors.
   D. religion, spirituality, culture, and values.

Answer 20

C

Question 21

SAFETY ALERT
The single most important action to prevent an infection is hand hygiene. Contact transmission from the hands of healthcare providers to patients is the most common mode of transmission because microorganisms from one patient are then spread to others (CDC, 2019).

Question 22

SAFETY ALERT
Gloves are never worn from the room out into the hallway, to decrease the risk of carrying microbes from a “dirty” room to a “clean” area or from an infected patient to another person.
Gloves are also removed when going from the bedside to the computer. The computer is mobile. If gloves touch an infected patient, especially when soiled, and the computer moves into the hall and into another patient’s room, the infection is carried to another patient’s room. Other people also touch the computer and can carry infection to other patients.

Question 23

6. The patient is complaining of abdominal pain. What technique is used to form an overall impression?
   A. Auscultation
   B. Light palpation
   C. Direct percussion
   D. Deep palpation

Answer 23

B

Question 23

SAFETY ALERT
Brace the ulnar surface or fingers of the hand against the patient’s cheek. This positioning allows you to move with the patient if the patient moves unexpectedly, as might happen with a child who has ear tenderness related to an infection.

Question 23

SAFETY ALERT
Be aware that some devices are placed to limit mobility, such as a brace for the back or neck. It is important to become familiar with guidelines for safe care and to have additional staff available to assist with splinting. If such devices are improperly released, damage to the nerve, muscle, or vascu-lature may occur.

Question 24

SAFETY ALERT
Patients can develop an allergy to latex at any time, especially those ho are frequently admitted to the hospital.
Reactions may range from a mild rash to overwhelming anaphylaxis. Emergency measures must be available for severe allergies.

Question 25

1. Which of the following interventions is most important to prevent nosocomial infections?
   A. Proper glove use
   B. Hand hygiene
   C. Appropriate draping
   D. Quiet environment

Question 25

SAFETY ALERT
Deep palpation should not be used over areas that pose a risk of injuring patients, such as over an enlarged spleen or inflamed appendix.

Question 26

2. Standard precautions
   A. are used on every patient because it is not always known whether a patient is infected.
   B. state that hand gel is used for infection with Clostridium difficile.
   C. include the use of gowns, gloves, and masks with all patients.
   D. recognize that transmission-based precautions are common.

Answer 26

A

Question 27

9. What technique facilitates accurate auscultation?
   A. Earpieces of the stethoscope are positioned to point toward the back.
   B. The tubing of the stethoscope is long and dark in color.
   C. The chestpiece of the stethoscope is sealed against the skin.
   D. The diaphragm of the stethoscope is used for low-frequency sounds.

Answer 27

C

Question 27

3. Latex allergies
   A. always result in anaphylactic reactions and shock.
   B. can be reduced by moisturizing the hands after washing.
   C. cannot be caused by equipment such as a stethoscope.
   D. are more common in nurses and in frequently hospitalized patients.

Answer 27

D

Question 28

5. Which of the following is an example of inspection?
   A. Heart rate and rhythm regular
   B. Lungs clear
   C. Abdomen tympanic
   D. Skin pink

Answer 28

D

Question 28

4. Which of the following is an appropriate use of gloves?
   A. Gloves are worn during anticipated contact with intact skin.
   B. Gloves are removed when going from clean to contaminated areas.
   C. Gloves are worn during anticipated contact with body secretions.
   D. Gloves are removed when assessing the back of an incontinent patient.

Answer 28

C

Question 29

10. When assessing a child, the nurse makes the following adaptation to the usual techniques:
    A. A pediatric stethoscope is used for better contact.
    B. The child is seated away from the parent.
    C. The room is full of toys for play.
    D. The child is undressed, including the diaper.

Answer 29

A

Question 29

7. Tympany is a percussion sound commonly located in the
   A. thorax.
   B. upper arm.
   C. abdomen.
   D. lower leg.

Answer 29

C

Question 30

8. Which organs or body areas does the nurse auscul-tate as part of the admitting assessment?
   A. Heart, lungs, and abdomen
   B. Kidneys, bladder, and ureters
   C. Abdomen, flank, and groin
   D. Neck, jaw, and clavicle

Answer 30

A

Question 31

SAFETY ALERT
The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. In the legal world, a typical saying is, “If it’s not documented, it’s not done.”

Question 32

Frequently, patients show clinical signs of deterioration, but healthcare providers fail to respond before a critical adverse event. This shows the importance of first making an excellent assessment, and secondly taking action. Clinical judgment is used as you consider, “what matters most?”,”where do I start?” “ what could it mean?”, “what can I do?”, and “what will I do?”. Documentation and follow-up on these
of trends in vital signs assessments and intervention is critical.

Question 33

SAFETY ALERT
Medicare and Medicaid have stopped reimbursement for some hospital-acquired complications, referred to as never events, because they are preventable through the use of evidence-based guidelines and should never occur. Examples include foreign objects left in the body after surgery, catheter-associated urinary tract infections, stage 3 or 4 pressure ulcers, and falls resulting in trauma. It is crucial for all nurses to document preexisting conditions and all assessment data related to “never events” to ensure proper hospital reimbursement.

Question 34

SAFETY ALERT
Healthcare providers who violate HIPAA may face fines of up to $1,806,757 or jail time (HIPAA, 2022). Employees have been terminated for breaching HIPAA laws concerning confidentiality. Nursing students also have accountability for keeping HIPAA laws and can face penalties for violations.

Question 35

SAFETY ALERT
Nursing students must be careful to deidentify any patient information in written assignments to be HIPAA compliant.
Never take forms from the agency, even if the patient identification information is removed. Instead, copy information from the patient’s chart into a notebook, without the patient’s name. No printed forms should be removed from the facility.
Pictures of forms and data are also not allowed. Many agencies do not allow phones in the clinical setting at all.

Question 36

SAFETY ALERT
CUS is a TeamSTEPPS communication tool to express concerns and uses standard terms: I am Concerned! I am Uncomfortable! This is a Safety Issue! This is commonly called “cuss” as a way to remember. All staff are instructed to listen clearly to the words concerned, uncomfortable, and stop; this is a safety risk.

Question 37

SAFETY ALERT
Students do not take telephone orders-only licensed nurses can do so. Nurses will always “read back” an order to the primary care provider to make sure that it is correct.

Question 38

1. Which of the following are advantages of the electronic medical record? (Select all that apply.)
   A. Nurses can enter data by checking boxes and adding free full text.
   B. It is economical and easy to learn and implement.
   G It allows primary care providers to directly order into the computer.
   D. It cannot be used as a legal document in case of a lawsuit.

Answer 38

AC

Question 39

2. Select all of the documentation errors that are potentially high risk. (Select all that apply.)
   A. Failure to document completely
   B. Inadequate admission assessment
   C. Charting in advance
   D. Bunch charting at the end of shift

Answer 39

ABCD

Question 40

3. The purpose of auditing charting is to
   A. enhance nurses’ learning and understanding of complex clinical situations.
   B. identify staff members who document completely and counsel those who do not.
   C. determine whether staff members are providing and documenting standards of care.
   D. locate data in the chart the evening before a morning clinical visit.

Answer 40

C

Question 41

4. Select all actions that are acceptable under the
   HIPAA Privacy Rule. (Select all that apply.)
   A. Communicate report with the next nurse during change of shift.
   B. Communicate with the primary care provider about a patient’s change in assessment.
   C. Consult in the hall with the instructor about the patient’s abnormal findings.
   D. Describe patient assessment findings to a colleague in the cafeteria.

Answer 41

A,B

Question 42

7. Strategies for effective handoffs during change-of-shift report are to
   A. tape-record the report for efficiency.
   B. vary the format to individualize to the patient. allow an opportunity to ask and answer questions.
   D. put report in writing so that the next shift care provider can get right to work.C

Answer 42

C

Question 43

8. In the SBAR reporting format, which of the following would be an example of data found in the assessment?
   A. Mrs. Kelly’s diagnosis is Stage II breast cancer.
   B Mr. Imami’s lung sounds are decreased.
   C. Ms. Choi needs to have a social work consult.
   D. Mr. Jones was admitted at 10:30 this morning.

Answer 43

B

Question 44

9. Nursing assessment of trends in an unconscious patient’s neurological status over time is best recorded on
   A. an admission assessment.
   В. а РОС.
   C. a progress note.
   D. a focused assessment flow sheet.

Answer 44

D

Question 45

10. Your patient with a humerus fracture is stating pain of 5 on a 10-point scale. Their hand is pale, cool, and swollen. The pain medication is ineffective, and they are at risk for impaired circulation. What action will the nurse take first?
    A. Reassess the pain in 30 minutes and contact the provider if unresolved.
    B. Give additional pain medication and reassess the pain in 30 minutes.
    C. Document the abnormal findings and give an extra dose of pain medication now.
    D. Contact the primary care provider and document the findings now.

Answer 45

D

Question 46

5. The proper technique for correcting written documentation is to
   A. use correction fluid and write over the error.
   B. completely black out the error with a black marker.
   C.write over the error in darker ink.
   D. draw a line through the error and write the date, time, reason for error, and your initials.

Answer 46

D

Question 47

When prioritizing you first adress any life threatening situations and then other issues that need immediate attention

Question 48

Bc your performing a real assessment on others you must be prepared to follow up if findings are abnormal. Always use appropriate safety techniques and order of assessment: inspect, palpate, percuss, and auscultate. An exception to the order is to inspect, then auscultate, percuss, and lastly palpate abdomen. This order of objective data collection follows the subjective data collection and health history

Question 49

Each agency develops sections and forms that are in a specific order. The nurse gains a system of going through the record to quickly choose the information needed for the situation. For example, the nurse clicks on allergies, orders, and medication records to see what medication may be given for pain

Question 50

Nurses’ intuitive feelings of worry or concern are extremely valuable in the process of recognizing deteriorating patients. These feelings of worry and concern must be documented and communicated to others. Nurses’ judgment, pattern recognition skills, and analytical assessment all enter into intuition. Sepsis and acute respiratory failure are two conditions that nurses can use intuition to anticipate before a true deterioration event occurs.

Question 51

Clear documentation that reflects time sequencing is especially important for patients with unstable conditions. If litigation occurs, lawyers use documentation to reconstruct the sequence of events, the time of interventions, and the time that primary care providers were notified. In a code or emergency situation (Fig. 4.2), the team designates a single member to document so that entries are accurate and timely.

Question 52

Because assessment requires much critical thinking and clinical judgment and is a professional respons-ibility, the nurse cannot delegate the assessment to UAP (eg., nurses’ aides).

Question 53

Although a primary care provider’s order determines the minimum frequency of assessments, the nurse can independently decide to increase the frequency and documentation of assessments if a patient’s condition appears unstable or deteriorating.
Nurses also use clinical judgment about when to notify the primary care provider regarding abnormal findings. Be sure to document such reporting, including the name and title of the provider, the time of notification, and the primary care provider’s response. Follow the chain of command and document it carefully if the response is unsatisfactory.

Question 54

To minimize potential errors from lack of informa-tion, agencies often provide specific assessments on a written transfer summary in addition to a verbal report. Some agencies have created specific forms for this transfer of information, whereas others require documentation in the progress notes.