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arvis:72 physical exam and health assessment chapter 1 Quiz Questions Well Answered|44 Pages
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Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning. - โ โ A The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinicians experience. d. The patients own preferences are not important with EBP. - โ โ C 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.
Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant - โ โ B The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis.
a. Nursing b. Medical c. Admission d. Collaborative - โ โ A The nursing process is a sequential method of problem solving that nurses use and includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation - โ โ D 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?
a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain
b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills. - โ โ A What step of the nursing process includes data collection by health history, physical examination, and interview?
a. Planning b. Diagnosis c. Evaluation d. Assessment - โ โ D During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making
into their practice. Which suggestion by the nurse manager would best help these problems?
a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies. - โ โ D When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?
a. Disease originates from the external environment. b. The individual human is a closed system.
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm. - โ โ D A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?
a. A follow-up data base to evaluate changes at appropriate intervals b.
An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly - โ โ C Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms. - โ โ D
a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit. - โ โ B A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
a. Identify the cause of his illness. b. Make accurate disease diagnoses. c.
Provide cultural health rights for the individual. d. Provide culturally sensitive and appropriate care. - โ โ D In the health promotion model, the focus of the health professional includes:
a. Changing the patients perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. Helping the consumer choose a healthier lifestyle. - โ โ D The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
a.
d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient. - โ โ D
. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute - โ โ A C E F a.
A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. b. A teenager who was stung by a bee during a soccer match is having trouble breathing. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation. problem - โ โ 1. a = First-level priority problem
Dullness
Tympany
Resonance
Hyperresonance - โ โ ANS: 1
myophagia. - โ โ ANS: 3 Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
Percuss and palpate in the lumbar region.
Inspect and palpate in the epigastric region.
Auscultate and percuss in the inguinal region.
Percuss and palpate the midline area above the suprapubic bone. - โ โ ANS: 4 Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation. The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is:
increased salivation.
decreased peristalsis.
increased esophageal emptying.
decreased gastric acid secretion. - โ โ ANS: 4 As one ages, salivation decreases, esophageal emptying is delayed, and peristalsis is thought to remain fairly constant. Gastric acid secretion decreases with aging. Decreased peristalsis may result from decreased bulk in diet, decreased fluid intake, or laxative abuse. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of the following is true regarding assessment of the spleen in this situation?
The spleen can be enlarged as a result of trauma.
The spleen is normally felt upon routine palpation.
If an enlarged spleen is noted, palpate thoroughly to determine size.
