Midterm Exam Flashcards
Which adjustment in the physical environment should the nurse make to promote the success of an interview?
The nurse should secure a quiet environment, turning off distractions such as the TV or Radio. Pt and nurse should be 4-5ft apart in a well lit room with equal status seating and eye level.
During an assessment of a patient’s family history, the nurse constructs a genogram. What is a genogram?
A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings).
he nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
Health promotion refers to activities that promote a person’s health. For a man that includes the performance of testicular self-examinations.
What is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting?
The most important step to decrease the risk for microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed.
When would you use Standard Precautions in the health care setting?
Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status.
What information obtained by the nurse regarding a patient’s skin should the nurse record in the patient’s health history?
Anything that is subjective, such as patient denies any color change, whatever the person says about him or herself. Objective data would be location, size etc-anything that the nurse observed.
When checking for proper blood pressure cuff size, what is the guidance?
The width of the rubber bladder should equal 40% of the circumference of the person’s arm. The length of the bladder should equal 80% of this circumference.
Which technique is correct when the nurse is assessing the radial pulse of a patient?
a. Palpate for 10 seconds and multiply by 6, if the rhythm is regular and the patient has no history of cardiac abnormalities.
b. Palpate for 15 seconds and multiply by 4, if the rhythm is regular.
c. Palpate for 2 full minutes to detect any variation in amplitude.
d. Palpate for 1 minute, if the rhythm is irregular.
Palpate for 1 minute, if the rhythm is irregular.
Research suggests that the 30-second interval multiplied by 2 is a more accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular, then the 15-seconds interval multiplied by 4 as any one beat error in counting results in an error of 4 beats/minute. If the rhythm is irregular, then the pulse is counted for 1 full minute.
When planning a cultural assessment, the nurse should include which component?
Health-related beliefs and practices are one component of a cultural assessment.
During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating “the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society” reflects which term?
The culture that develops in any given society is unique, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society.
What are norms?
Norms refer to the typical or normal
What is ethnicity?
Ethnicity refers to a social group that may possess shared traits, such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences.
What is assimilation?
Assimilation refers to taking on the characteristics of the dominant culture.
he nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one’s spirituality?
a. Attendance at a specific church or place of worship
b. Belief in and the worship of God or gods
c. A connection with something larger than oneself and belief in transcendence
d. Being closely tied to one’s ethnic background
Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Belief in and the worship of God or gods and attendance at a specific church or place of worship apply to religion. Being closely tied to one’s ethnic background is not a concept of spirituality or religion.
The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take?
a. Ask the patient to read her health record and indicate any changes since her last visit.
b. Check the patient’s blood pressure.
c. Obtain a complete health history on the patient before checking her blood pressure.
d. Collect a follow-up database and then check the patient’s blood pressure.
Collect a follow-up database and then check the patient’s blood pressure.
What is a general survey?
The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior. Interpreting subjective data is not part of the general survey.
Measuring the patient’s vital signs (temperature, pulse, respirations, and blood pressure) and observing specific body systems while performing a physical assessment are part of the physical examination, not the general survey.
A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of assessment data is this?
Subjective data is what the person says about him or herself during history taking.
What is objective data?
Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
a. Severely abnormal vital signs
b. Low self-esteem
c. Lack of knowledge
d. Abnormal laboratory values
d. Abnormal laboratory values
Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security).
What are third-level priority problems?
Low self-esteem and lack of knowledge are considered third-level priority as although they are important to a patient’s health, they can be addressed after more urgent health problems are addressed
What data should the nurse collect during the interview portion of a health assessment?
Subjective
The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data; that is, what the person says about him or herself.
What type of data is collected during the physical portion of the health assessment?
Physical data/Objective Data
During an interview, the nurse states, “You mentioned having shortness of breath. Tell me more about that.” Which verbal skill is used with this statement?
Open-ended question
Why should a nurse used open ended questions?
Open-ended questions ask for narrative information and give the patient free rein. They state the topic to be discussed but only in general terms, which is what the statement in this question does.
When should a nurse use open ended questions during an interview?
The nurse should use open-ended questions to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.
A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” Which is the best reply by the nurse?
The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”
What is systolic pressure?
The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole.
What is diastolic pressure?
The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction.
What is stroke volume?
Stroke volume is a term used in cardiovascular physiology to refer to the amount of blood pumped by the heart with each beat.
How is stroke volume determined?
Stroke volume is determined by the volume of blood that enters the heart’s ventricles during diastole (the filling phase of the cardiac cycle) and the amount of blood that is ejected from the ventricles during systole (the pumping phase of the cardiac cycle).
What is cardiac output?
Cardiac output is a term used to describe the volume of blood that is pumped by the heart in a given time period, usually expressed as liters per minute.
When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure?
200/92
In adults, the last audible sound best indicates the diastolic pressure. When a variance is greater than 10 to 12 mm Hg between phases IV and V, both phases should be recorded along with the systolic reading (e.g., 142/98/80).
A patient is seen in the clinic for complaints of “fainting episodes that started last week.” How should the nurse proceed with the examination?
His blood pressure is recorded in the lying, sitting, and standing positions.
If the person is known to have hypertension, is taking antihypertensive medications, or reports a history of fainting or syncope, then the blood pressure reading and pulse should be taken in three positions: lying, sitting, and standing. This is called orthostatic, or postural, vital signs.
During an assessment, the nurse notes that the patient’s apical impulse is laterally displaced and is palpable over a wide area. What does this finding indicate?
Volume overload, as in heart failure or cardiomyopathy
What effect does volume overload have on the heart?
With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally displaces the apical impulse and is palpable over a wider area when left ventricular hypertrophy and dilation are present.
A thrill in the second and third right interspaces indicates?
systemic hypertension and aortic stenosis
A thrill in the second and third left interspaces indicates?
pulmonic hypertension
A bruit heard while auscultating the carotid artery of a 65-year-old patient is caused by?
turbulent blood flow through the carotid artery.
What is a carotid bruit?
A carotid bruit is a blowing, swishing sound indicating blood flow turbulence. A bruit indicates atherosclerotic narrowing of the vessel.
The student nurse demonstrates correct technique in using the stethoscope to auscultate heart sounds when he/she does which of the following?
a.Makes sure earpieces fit snugly and are pointed to their nose.
b.Uses the bell to detect higher pitched sounds.
c.Performs assessment while the patient is watching television.
d.Auscultates in only 4 locations.
a.Makes sure earpieces fit snugly and are pointed to their nose.
What are the different uses for the diaphram and bell of the stethoscope?
The diaphragm of the stethoscope is used for higher pitched sounds and the bell for lower pitched sounds
The nurse is preparing to teach a class on cardiovascular assessment. When explaining a thrill, what should the nurse include in the teaching?
A vibration that is palpable
What is a thrill?
A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud murmurs.
The absence of a thrill does not rule out what?
The absence of a thrill does not rule out the presence of a murmur.
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. What does this finding indicate?
A bruit
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.
During a skin assessment, the nurse notices that a patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient’s scleras are white. From these findings, what can the nurse rule out?
a.Pallor
b.Cyanosis
c.Iron deficiency
d.Jaundice
Jaundice
What is jaundice and were is it observed?
Jaundice is exhibited by a yellow color of the skin and mucous membranes, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.
What is pallor?
Pallor occurs when the red-pink tones from oxygenated Hb are lost and the skin takes on the color of the connective tissue (collagen) which is mostly white.
What can an iron deficiency due to the nails?
Iron deficiency can cause nails with a concave (spoon-like) shape.
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?
Basal cell carcinoma
What is the most common form of skin cancer?
Basal cell carcinoma
What is basal cell carcinoma?
Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer.
How does acne present?
Acne presents as pustules (turbid fluid filled cavities) that are circumscribed and elevated
