QUESTION AND ANSWERS TO EACH CHAPTER | Study notes Nursing

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A school nurse is teaching a 14-year-old girl of normal weight some of the key factors

necessary to maintain good nutrition in this stage of her growth and development. What

interventions should the nurse most likely prioritize?

Decreasing her calorie intake and encouraging her to maintain her weight to

avoid obesity

Increasing her BMI, taking a multivitamin, and discussing body image

Increasing calcium intake, eating a balanced diet, and discussing eating disorders

Obtaining a food diary along with providing close monitoring for anorexia

Ans:

Feedback:

Adolescent girls are considered to be at high risk for nutritional disorders. Increasing

calcium intake and promoting a balanced diet will provide the necessary vitamins and

minerals. If adolescents are diagnosed with eating disorders early, the recovery chances

are increased. The question presents no information that indicates a need for decreasing

her calories. There is no apparent need for an increase in BMI. A food diary is used for

assessing eating habits, but the question asks for teaching factors related to good

nutrition.

A nurse is conducting a health assessment of an adult patient when the patient asks,

“Why do you need all this health information and who is going to see it?” What is the

nurse's best response?

“Please do not worry. It is safe and will be used only to help us with your care.

It's accessible to a wide variety of people who are invested in your health.”

“It is good you asked and you have a right to know; your information helps us to

provide you with the best possible care, and your records are in a secure place.”

“Your health information is placed on secure Web sites to provide easy access to

anyone wishing to see your medical records. This ensures continuity of care.”

“Health information becomes the property of the hospital and we will make sure

that no one sees it. Then, in 2 years, we destroy all records and the process starts

over.”

Ans:

Feedback:

Whenever information is elicited from a person through a health history or physical

examination, the person has the right to know why the information is sought and how it

will be used. For this reason, it is important to explain what the history and physical

examination are, how the information will be obtained, and how it will be used.

Medical records allow access to health care providers who need the information to

provide patients with the best possible care, and the records are always held in a secure

environment. Telling the patient “not to worry” minimizes the patient's concern

regarding the safety of his or her health information and “a wide variety of people”

should not have access to patients' health information. Health information should not be

placed on Web sites and health records are not destroyed every 2 years.

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A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize? A) Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity B) Increasing her BMI, taking a multivitamin, and discussing body image C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders D) Obtaining a food diary along with providing close monitoring for anorexia Ans: C Feedback: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased. The question presents no information that indicates a need for decreasing her calories. There is no apparent need for an increase in BMI. A food diary is used for assessing eating habits, but the question asks for teaching factors related to good nutrition.
A nurse is conducting a health assessment of an adult patient when the patient asks, “Why do you need all this health information and who is going to see it?” What is the nurse's best response? A) “Please do not worry. It is safe and will be used only to help us with your care. It's accessible to a wide variety of people who are invested in your health.” B) “It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place.” C) “Your health information is placed on secure Web sites to provide easy access to anyone wishing to see your medical records. This ensures continuity of care.” D) “Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over.” Ans: B Feedback: Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used. Medical records allow access to health care providers who need the information to provide patients with the best possible care, and the records are always held in a secure environment. Telling the patient “not to worry” minimizes the patient's concern regarding the safety of his or her health information and “a wide variety of people” should not have access to patients' health information. Health information should not be placed on Web sites and health records are not destroyed every 2 years.

The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patient's language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection? A) Have a family member provide the data. B) Obtain the data from the old chart and physician's assessment. C) Obtain the data only from the patient, prioritizing aspects that the patient understands. D) Collect all possible data from the patient and have the family supplement missing details. Ans: D Feedback: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.
You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patient's upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising? A) “Is anyone physically hurting you?” B) “Tell me about your relationships.” C) “Do you want to see a social worker?” D) “Is there something you want to tell me?” Ans: A Feedback: Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, “Is anyone physically hurting you?” The other options are incorrect because they are not the best way to illicit information about possible abuse in a direct and appropriate manner.

A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurse's assessment? A) The patient's spiritual environment can affect his physical activity. B) The patient's spiritual environment can affect his ability to communicate. C) The patient's spiritual environment can affect his quality of sexual relationships. D) The patient's spiritual environment can affect his response to illness. Ans: D Feedback: Illness may cause a spiritual crisis and can place considerable stresses on a person's internal resources. The term spiritual environment refers to the degree to which a person has contemplated his or her own existence. The other listed options may be right, but they are not the most important reasons for a nurse to assess a patient's spiritual environment.
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patient's statement? A) The patient does not understand the principles of nutrition. B) This is an aspect of the patient's religious practice. C) This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition. D) This is an example of the patient's coping strategies. Ans: B Feedback: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patient's religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition.

You are beginning your shift on a medical unit and are performing assessments appropriate to each patient's diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the patient's neck? A) Inspection B) Auscultation C) Palpation D) Percussion Ans: C Feedback: Palpation is a part of the assessment that allows the nurse to assess a body part through touch. Many structures of the body (superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum), although not visible, may be assessed through the techniques of light and deep palpation. The other options are incorrect because lymph nodes are not assessed through inspection, auscultation, or percussion.
In your role as a school nurse, you are working with a female high school junior whose BMI is 31. When planning this girl's care, you should identify what goal? A) Continuation of current diet and activity level B) Increase in exercise and reduction in calorie intake C) Possible referral to an eating disorder clinic D) Increase in daily calorie intake Ans: B Feedback: A BMI of 31 is considered clinically obese; dietary and exercise modifications would be indicated. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29.9 are considered overweight; those with a BMI of 30 or greater are considered to be obese.

You are teaching a nutrition education class that is being held for a group of older adults at a senior center. When planning your teaching, you should be aware that individuals at this point in the lifespan have which of the following? A) A decreased need for calcium B) An increased need for glucose C) An increased need for sodium D) A decreased need for calories Ans: D Feedback: The older adult has a decreased metabolism, and absorption of nutrients has decreased. The older adult has an increased need for sound nutrition but a decreased need for calories. The other options are incorrect because there is no decreased need for calcium and no increased need for either glucose or sodium.
You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint? A) “Why do you think your abdomen is painful?” B) “Where exactly is your abdominal pain and when did it start?” C) “What brings you to the hospital today?” D) “What is wrong with you today?” Ans: C Feedback: The chief complaint should clearly address what has brought the patient to see the health care provider; an open-ended question best serves this purpose. The question “What brings you to the hospital?” allows the patient sufficient latitude to provide an answer that expresses the priority issue. Focusing solely on abdominal pain would be too specific to serve as the first question regarding the chief complaint. Asking, “What is wrong with you today?” is an open-ended question but still directs the patient toward the fact that there is a problem.

You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type 2 diabetes. Which question would best provide you with information about the role of food in the patient's cultural practices and identify how the patient's food preferences could be related to his problem? A) “Do you feel any of your cultural practices have a negative impact on your disease process?” B) “What types of foods are served as a part of your cultural practices, and how are they prepared?” C) “As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care?” D) “Tell me about foods that are important in your culture and how you feel they influence your diabetes.” Ans: D Feedback: The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. Food plays a significant role in both cultural practices and type 2 diabetes. By asking the question, “Tell me about the foods that are important in your culture and how you feel they influence your diabetes,” the nurse demonstrates a cultural awareness to the client and allows an open-ended discussion of the disease process and its relationship to cultural practice. An overemphasis on negatives can inhibit assessment and communication. Assessing the types and preparation of foods specific to cultural practices without relating it to diabetes is inadequate. The question, “As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care?” focuses on “care” and fails to address the significance of food in cultural practice or diabetes.
An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question? A) “Tell me about your medications: How do you usually get them each day?” B) “Tell me about where you live: Do you feel your needs are being met, and do you feel safe?” C) “Your wheelchair would seem to limit your ability to move around. How do you deal with that?” D) “What limitations are you dealing with related to your health and being in a wheelchair?” Ans: B Feedback: The question, “Tell me about where you live: Do you feel your needs are being met and do you feel safe?” seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. An explicit focus on limitations may be counterproductive.

In your role as a school nurse, you are performing a sports physical on a healthy adolescent girl who is planning to try out for the volleyball team. When it comes time to listen to the student's heart and lungs, what is your best nursing action? A) Perform auscultation with the stethoscope placed firmly over her clothing to protect her privacy. B) Perform auscultation by holding the diaphragm lightly on her clothing to eliminate the “scratchy noise.” C) Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise. D) Defer the exam because the girl is known to be healthy and chest auscultation may cause her anxiety. Ans: C Feedback: Auscultation should always be performed with the diaphragm placed firmly on the skin to minimize extra noise and with the bell lightly placed on the skin to reduce distortion caused by vibration. Placing a stethoscope over clothing limits the conduction of sound. Performing auscultation is an important part of a sports physical and should never be deferred.
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate? A) The patient is a normal weight. B) The patient is extremely obese. C) The patient is overweight. D) The patient is mildly obese. Ans: B Feedback: Individuals who have a BMI between 25 and 29.9 are considered overweight. Obesity is defined as a BMI of greater than 30 (WHO, 2011). A BMI of 45 would indicate extreme obesity.

A nurse is conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables? A) Availability of home health care, current Medicare rules, and family support B) The community and home environment, support systems or family care, and the availability of needed resources C) The future health status of the individual, and community and hospital resources D) The characteristics of the neighborhood, and the patient's socioeconomic status and insurance coverage Ans: B Feedback: The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. The other options fail to address the specifics of either the community or home environment.
You are performing the admission assessment of a patient who is being admitted to the postsurgical unit following knee arthroplasty. The patient states, “You've got more information on me now than my own family has. How do you manage to keep it all private?” What is your best response to this patient's concern? A) “Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it.” B) “Your information is available only to people who currently work in patient care here in the hospital.” C) “Your information is kept electronically on a secure server and anyone who gets permission from you can see it.” D) “Your information is only available to professionals who care for you and representatives of your insurance company.” Ans: A Feedback: This written record of the patient's history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. Only those caring for the patient have access to the health record. Insurance companies have the right to know the patient's coded diagnoses so that bills may be paid; they are not privy to the health record.

You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. The patient wants to know why the hospital needs all this information about the way he eats, asking you, “Are you asking me all these questions because I am Middle Eastern?” What is your best response to this patient? A) “We always try to abide by foreign-born patients' dietary preferences in order to make them comfortable.” B) “We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these.” C) “We wouldn't want to feed you anything you only eat on certain holidays.” D) “We know that patients who grew up in other countries often have unusual diets, and we want to accommodate this.” Ans: B Feedback: Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. A specific focus on holidays, however, does not convey the overall intent of the dietary interview. Dietary planning addresses all patients' needs, not only those who are born outside the United States. It is inappropriate to characterize a patient's diet as “unusual.”
You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient? A) The U.S. Department of Agriculture's MyPlate B) Evidence-based resources on nutritional assessment C) Culturally sensitive materials, such as the Mediterranean Pyramid D) A Greek cookbook that contains academic references Ans: C Feedback: Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. MyPlate is not explicitly culturally sensitive. Nursing resource books do not usually have culturally sensitive dietary specific material. A Greek cookbook would not be an appropriate clinical resource.

In the course of performing an admission assessment, the nurse has asked questions about the patient's first- and second-order relatives. What is the primary rationale for the nurse's line of questioning? A) To determine how many living relatives the patient has B) To identify the family's level of health literacy C) To identify potential sources of social support D) To identify diseases that may be genetic Ans: D Feedback: To identify diseases that may be genetic, communicable, or possibly environmental in origin, the interviewer asks about the age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins). This is a priority over the number of living relatives, sources of support, or health literacy, though each of these may be relevant.
The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? Select all that apply. A) Allergies B) Alcoholism C) Psoriasis D) Hypervitaminosis E) Obesity Ans: A, B, E Feedback: In general, the following conditions are included in a family history: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity. Psoriasis and hypervitaminosis do not have genetic etiologies.

A nurse practitioner's assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which of the following is the nurse able to assess? A) Borders of the patient's heart B) Movement of the patient's diaphragm during expiration C) Borders of the patient's liver D) The presence of rectal distension Ans: A Feedback: Percussion allows the examiner to assess such normal anatomic details as the borders of the heart and the movement of the diaphragm during inspiration. Movement of the diaphragm, delineation of the liver and the presence of rectal distention cannot be assessed by percussion.
A 51-year-old woman's recent complaints of fatigue are thought to be attributable to iron-deficiency anemia. The patient's subsequent diagnostic testing includes quantification of her transferrin levels. This biochemical assessment would be performed by assessing which of the following? A) The patient's urine B) The patient's serum C) The patient's cerebrospinal fluid D) The patient's synovial fluid Ans: B Feedback: Biochemical assessments are made from studies of serum (albumin, transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). Transferrin is found in serum, not urine, CSF, or synovial fluid.
An older adult's unexplained weight loss of 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurse's rationale for prioritizing biochemical assessment when appraising a person's nutritional status? A) It identifies abnormalities in the chemical structure of nutrients. B) It predicts abnormal utilization of nutrients. C) It reflects the tissue level of a given nutrient. D) It predicts metabolic abnormalities in nutritional intake. Ans: C Feedback: Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. It does not focus on abnormalities in the chemical structure of nutrients. Biochemical assessment is not predictive.

A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age? A) Protein intake in this age group often falls below recommended levels. B) Total calorie intake is often insufficient at this age. C) Calcium intake is above the recommended levels. D) Folate intake is below the recommended levels in this age group. Ans: D Feedback: Adolescent girls are at particular nutritional risk, because iron, folate, and calcium intakes are below recommended levels, and they are a less physically active group compared to adolescent males. Protein and calorie intake is most often sufficient.
A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years? A) Lifelong eating habits are acquired. B) Peer pressure influences growth. C) BMI is determined. D) Culture begins to influence diet. Ans: A Feedback: Adolescence is a time of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, analysis, and intervention are critical. Peer pressure does not influence growth. Cultural influences tend to become less important during the teen years; they do not emerge for the first time at this age. BMI can be assessed at any age.

Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should the nurse be aware of when assessing patients? A) Masking the symptoms of acute infection B) Decreasing wound healing time C) Contributing to shorter hospital stays D) Prolonging confinement to bed Ans: D Feedback: Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Malnutrition does not mask the signs and symptoms of acute infection.
A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital? A) A physical assessment in the community consists of largely the same techniques as are used in the hospital. B) A physical assessment made in the community does not require the privacy that a physical assessment made in the hospital setting requires. C) A physical assessment made in the community requires that the patient be made more comfortable than would be necessary in the hospital setting. D) A physical assessment made in the community varies in technique from that conducted in the hospital setting by being less structured. Ans: A Feedback: The physical assessment in the community and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, and the person is made as comfortable as possible. The importance of comfort, privacy and structure are similar in both settings.

You are conducting an assessment of a patient in her home setting. Your patient is a 91-year-old woman who lives alone and has no family members living close by. What would you need to be aware of to aid in providing care to this patient? A) Where the closest relative lives B) What resources are available to the patient C) What the patient's financial status is D) How many children this patient has Ans: B Feedback: The nurse must be aware of resources available in the community and methods of obtaining those resources for the patient. The other data would be nice to know, but are not prerequisites to providing care to this patient.

QUESTION AND ANSWERS TO EACH CHAPTER, Study notes of Nursing

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