Review Questions from Textbook Flashcards
A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.)
- The review of patient data in the medical record
- Confirming a patient’s self-report of abdominal pain by inspecting the abdomen
- Reporting results of an ongoing assessment to a nurse working the next scheduled shift
- Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration
- Conducting an interview of a family caregiver
- The review of patient data in the medical record
- Confirming a patient’s self-report of abdominal pain by inspecting the abdomen
- Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration
- Conducting an interview of a family caregiver
- Assessment conducted at beginning of a nurse’s shift
- Review of a patient’s chief complaint
- Completion of admitting history at time of patient admission to a hospital
- Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home
Match:
A. Problem Focused
B. Comprehensive
- Assessment conducted at beginning of a nurse’s shift = problem focused
- Review of a patient’s chief complaint = problem focused
- Completion of admitting history at time of patient admission to a hospital = comprehensive
- Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home = comprehensive
A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient’s lungs and hears crackles in the left lower lobe. The patient’s respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, “It is hard for me to get a breath.” Which of the following data sets are examples of subjective data? (Select all that apply.)
- Heart rate of 20 per minute and chest congestion
- Lung sounds revealing crackles and use of intercostal muscles to breathe
- Patient statement, “It’s hard for me to get a breath”
- Slumped posture and previous respiratory rate of 16 per minute
- Patient report of sore throat and hoarseness
- Patient statement, “It’s hard for me to get a breath”
5. Patient report of sore throat and hoarseness
The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?
- Orientation
- Working phase
- Data interpretation
- Termination
- Working phase
A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient’s cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, “Let me get through these questions first.” Which action interferes with the nurse’s ability to use connection as a communication skill.
- Introducing self to patient
- Using the computer as a prompt for questions
- Making the nurse’s questions a priority
- Assuring the patient all information is confidential
- Making the nurse’s questions a priority
A 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:
- Reflection.
- Clinical inference.
- Cue.
- Validation.
- Clinical inference
Place the following steps of the assessment process in the correct order.
- Compare data with another source to determine data accuracy.
- As a pattern forms, probe and frame further questions.
- Interview a patient, observe behavior, and gather physical assessment findings.
- Cluster cues that relate together, make inferences, and identify emerging patterns.
- Differentiate important data from the total data you collect.
3,5,4,2,1:
Interview a patient, observe behavior, and gather physical assessment findings. > Differentiate important data from the total data you collect. > Cluster cues that relate together, make inferences, and identify > As a pattern forms, probe and frame further questions. > Compare data with another source to determine data accuracy.
In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?226
- Current medications
- Patient expectations of planned surgery
- Review of patient’s family support system
- History of allergies
- Patient’s explanation for what might be the cause of symptoms that require surgery
Patient’s explanation for what might be the cause of symptoms that require surgery
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.
- “You say you’ve lost weight. Tell me how much weight you’ve lost in the past month.”
- “My name is Terry. I’ll be the nurse taking care of you today.”
- “I have no further questions. Is there anything else you wish to ask me?”
- “Tell me what brought you to the hospital.”
- “So, to summarize, you’ve lost about 6 pounds in the past month, and your appetite has been poor—correct?”
“My name is Terry. I’ll be the nurse taking care of you today.” > “Tell me what brought you to the hospital.” > “You say you’ve lost weight. Tell me how much weight you’ve lost in the past month.” > “So, to summarize, you’ve lost about 6 pounds in the past month, and your appetite has been poor—correct?” > “I have no further questions. Is there anything else you wish to ask me?”
Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.)
- Recognize normal changes associated with aging.
- Avoid direct eye contact.
- Lean forward and smile as you pose questions.
- Allow for pauses as patient tells his story.
- Use the list of questions from the clinic assessment form to complete all data.
Recognize normal changes associated with aging.
Lean forward and smile as you pose questions.
Allow for pauses as patient tells his story.
Which of the following is an example of a patient with a health disparity? (Select all that apply.)
- A patient who has a homosexual sexual preference
- A patient unable to access primary care services
- A patient living with a chronic disease
- A family who relies on public transportation
- A patient who has had a history of smoking for 10 years
- A patient unable to access primary care services
- A patient living with a chronic disease
- A patient who has had a history of smoking for 10 years
A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this woman’s health? (Select all that apply.)
- Medicaid insurance
- Annual screening
- Mother’s history of breast cancer
- Lack of transportation
- Woman’s age
- Medicaid insurance
- Lack of transportation
- Woman’s age
During a nursing assessment a patient displayed several behaviors. Which behavior suggests the patient may have a health literacy problem?
- Patient has difficulty completing a registration form at a medical office
- Patient asks for written information about a health topic
- Patient speaks Spanish as primary language
- Patient states unfamiliarity with a newly ordered medicine
Patient has difficulty completing a registration form at a medical office
A nurse desires to communicate with a young woman who is Serbian and who has limited experience with being in a hospital. The nurse has 10 years of experience caring for Serbian women. The patient was admitted for a serious pregnancy complication. Apply the LEARN model and match the nurse’s behaviors with each step of the model.
1. L ___________ a. The nurse notes that she has learned that fathers can visit mothers at any time in both Serbia and the United States.
2. E ___________ b. The nurse shares her perception of the woman’s experiences as a patient.
3. A ___________ c. The nurse asks the patient how she can maintain bed rest when she returns home.
Table Continued
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4. R __________ d. The nurse attends to the patient and listens to her story about hospitals in Serbia.
5. N __________ e. The nurse involves the patient in a discussion of the treatment options for her condition.
1d,2b,3a,4e,5c
Health care organizations must provide which of the following based on federal civil rights laws? (Select all that apply.)
- Provide language assistance services at all points of contact free of charge.
- Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services.
- Use patients’ family members to interpret difficult topics.
- Ensure that interpreters are competent in medical terminology.
- Provide language assistance to all patients who speak limited English or are deaf.
- Provide language assistance services at all points of contact free of charge.
- Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services.
- Provide language assistance to all patients who speak limited English or are deaf.
