CH 5
An individual is considered obese when his or her BMI is a) greater than 40. b) 25 to 29. c) 30 to 39. d) less than 24.
30 to 39. Explanation: Those persons with a BMI of 30 to 39 are considered obese. Persons with a BMI of less than 24 are at risk for problems associated with poor nutritional status. Persons with a BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered extremely obese.
A client who has lost weight asks a nurse about how much physical activity is needed to prevent regaining the weight. Which of the following would the nurse recommend? a) 45 minutes per day b) 15 minutes per day c) 60 minutes per day d) 30 minutes per day
60 minutes per day Explanation: According to MyPyramid, an individual should engage in 60 minutes of physical activity each day to prevent weight gain. Routinely, a person should engage in 30 minutes of physical activity each day to maintain health and 60 to 90 minutes per day to sustain weight loss.
A patient comes to the clinic at 8 a.m. for a scheduled visit. The nurse obtains the patient's temperature orally. Which finding would the nurse interpret as a potential indicator of a problem? a) 98.4 degrees F b) 99.6 degrees F c) 98.0 degrees F d) 97.2 degrees F
99.6 degrees F Explanation: A diurnal variation of 1 or 2 degrees in body temperature is normal throughout the day. Temperature is usually lowest in the morning and increases during the day to betweeen 99 to 99.5 degrees F and then decreases during the night. Therefore, an early morning temperature of 99.6 degrees would suggest a potential problem, because this temperature would then increase as the day goes on. Early morning temperatures of 97.2 degrees, 98.0 degrees, and 98.4 degrees would not be a cause for concern.
Which of the following statements made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history? a) "How has the stroke affected your ability to perform your daily activities?" b) "What has your daily blood pressure and pulse rate reading been?" c) "Have you been taking your blood pressure medication exactly as prescribed?" d) "Tell me about your family's history with heart disease."
"How has the stroke affected your ability to perform your daily activities?" Explanation: An emphasis on functional assessment is viewed as being more holistic than the traditional health or medical history. A patient's functional status is the ability of the patient to function normally and perform his or her usual physical, mental, and social activities. Questions related to blood pressure readings, family history, and medication regimen indicate a traditional or medical model versus a holistic health assessment.
Which question would help the nurse gather information about a client's lifestyle that may be a factor in the client's present illness? a) "How many cups of coffee do you drink each day?" b) "What language is spoken at your home?" c) "Is God important to you?" d) "How many steps do you have to climb to enter your house?"
"How many cups of coffee do you drink each day?" Explanation: The lifestyle section of the client profile provides information about health-related behaviors, including patterns of sleep, exercise, and nutrition and personal habits such as caffeine intake.
A nurse is assessing a patient's sexuality. Which of the following would be MOST appropriate for the nurse to use first when addressing this topic? a) "How many sexual partners have you had?" b) "How's your sex life been lately?" c) "Your record indicates that you've been divorced for several years." d) "I would like to ask you some questions about your sexual health."
"I would like to ask you some questions about your sexual health." Explanation: When approaching a sensitive issue such as sexuality, the nurse would first use an orienting statement or question, such as "I would like to ask you about your sexual health and practices." This then opens the door for further discussion. Beginning the assessment by asking about the patient's sex life, number of sexual partners, or being divorced is inappropriate and nontherapeutic.
Two nursing students are role-playing a patient assessment situation. One of the students is acting as the nurse, and the other student is acting as the patient. The task is to focus on assessing the patient's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask? a) "Where do you currently live?" b) "Can you tell me about your childhood?" c) "Where do your parents come from?" d) "What do you usually do for fun?"
"What do you usually do for fun?" Explanation: Assessing a patient's lifestyle involves questions related to behaviors such as sleep patterns, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of ilicit drugs, alcohol, and caffeine. The question about what the patient does for fun reflects activities. The question about where the patient lives provides information about the physical environment; the question about where the patient's parents came from provides information about culture, which is also part of the environment. The question about the patient's childhood provides information about the patient's past life events related to health.
While undergoing a health history and physical assessment, a patient states, "I'm really afraid this pain in my belly is cancer." Which response by the nurse would be MOST appropriate? a) "You seem upset about the pain. Tell me what's happening." b) "So you think you have cancer?" c) "We can't say yes or no until the doctor does some testing." d) "Let's not worry about that now. I need to get your information first."
"You seem upset about the pain. Tell me what's happening." Explanation: During the interview, it is essential that the nurse establish rapport, put the patient at ease, and listen to the patient carefully. The nurse's statement about the patient seeming upset is most consistent with these goals. Telling the patient not to worry now dismisses the patient's concerns. Questioning the patient about cancer focuses on the diagnosis, not the patient's current feelings and concerns. Although telling the patient that more testing is necessary can be helpful, the response does not address the patient's feelings and concerns.
A nursing student is learning to complete a focused abdominal assessment. She understands the necessity for altering the assessment skill sequence when examining this body region. Therefore, she will complete which skill after inspection? a) Percussion b) Light palpation c) Auscultation d) Deep palpation
Auscultation Explanation: The traditional sequence in the focused portion of the examination is inspection, palpation, percussion, and auscultation, except in the case of the abdomen. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.
A nurse is preparing to conduct a health assessment with a 78-year-old man who wears a hearing aid in his left ear. The patient is accompanied by his wife. Which of the following would be most appropriate? a) Have the patient sit at an angle to the nurse, with his good ear facing the nurse. b) Direct the interview to the patient's wife to ensure adequate information is obtained. c) Check to make sure that the patient has his hearing aid turned on and in place in his left ear. d) Keep the examination door open during the interview so the nurse can ask for help if needed.
Check to make sure that the patient has his hearing aid turned on and in place in his left ear. Explanation: When obtaining information from an older adult with a hearing deficit, the nurse should make sure that the patient's hearing aid is turned on and in place in the appropriate ear. The patient should be positioned so that he can read lips and facial expressions to augment verbal communication. Distracting noises should be kept to a minimum. Keeping the door open would increase the chances of distracting noises and could violate privacy. There is no need to direct the interview to the patient's wife just because the patient has a hearing deficit.
Which of the following is important for the nurse to consider during the preinterview period with an adult? a) Allow rest during the interview b) Establish rapport with the patient and family members c) Address the patient by his or her first name d) Keep the room cold and drafty
Establish rapport with the patient and family members Explanation: The preinterview period determines the direction of the interview process. The nurse should start by establishing rapport with the patient and family members and ensuring that the client is comfortable. During the introduction, the nurse should address the patient by his or her surname. The nurse should avoid tiring older patients by allowing rest periods during the physical examination and should also keep the room warm and free from drafts.
A student nurse walks into a patient's room and observes the patient chanting and holding his rosary. The patient pauses and asks the student nurse to join hands while he prays. What is the best action for the student nurse to take? a) Join hands with the patient and lead a prayer of behalf of the patient. b) Join hands with the patient and remain at the bedside until the patient finishes the prayer. c) Carefully explain to the patient that she is of a different faith and excuse herself from the room. d) Call the chaplain on duty to come pray with the patient.
Join hands with the patient and remain at the bedside until the patient finishes the prayer. Explanation: It is important that the spiritual beliefs of people and families be acknowledged, valued, and respected for the comfort and guidance they provide. Leaving the room based on the nurse's spiritual beliefs does not convey respect for the patient. It is within the scope of the nurse to support the patient's request for prayer and conveys respect for the patient's spirituality. The patient needs to remain in control of the prayer, speaking it as he or she is accustomed to doing it.
A client has monthly laboratory tests done. The nurse notes a decrease in the albumin level. What condition in the client's history could alter the albumin level? a) Dehydration b) Liver disease c) Endometriosis d) Pituitary cyst
Liver disease Explanation: Albumin levels are used as measures of protein in adults. Albumin systhesis depends on normal liver function. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss.
While reviewing a client's records, the nurse notes a reduction in weight of 15 pounds over the last month without dieting. What factor may be associated with this possible nutritional deficit? a) Drinking a glass of red wine every evening with dinner b) Starting two new medications 1 week ago c) Losing a spouse and only child in an accident 2 months ago d) Beginning to use a new set of upper dentures last week
Losing a spouse and only child in an accident 2 months ago Explanation: Depression can cause loss of appetite as well as desire for social interaction. Clients experiencing life changing events such as the death of loved ones often experience depression and loss the desire to eat or cook, which can lead to weight loss.
A nurse identifies a nursing diagnosis of "Anxiety related to hospitalization and uncertainity about diagnostic test results." Which of the following actions by the nurse will be an attempt to decrease client anxiety? a) Maintaining eye contact and carefully listening to client responses and concerns b) Giving advice about ways to decrease anxiety c) Giving the client space and asking only yes and no questions d) Staying on task and completing the health history questions
Maintaining eye contact and carefully listening to client responses and concerns Explanation: Clients seeking health care are often anxious. The nurse can reduce anxiety by attempting to establish rapport through honest communication, making eye contact, and listening crefully.
Which method of physical examination refers to the translation of physical force into sound? a) Auscultation b) Manipulation c) Percussion d) Palpation
Percussion Explanation: Percussion translates the application of physical force into sound. Palpation refers to examination by nonforceful touching. Auscultation refers to the skill of listening to sounds produced within the body created by movement of air or fluid. Manipulation refers to the use of the hands to determine motion of a body part.
The nurse is preparing the patient file for an 8-year-old child. The child's mother informs that her daughter has difficulty breathing at night, and makes a whistling sound while sleeping. Due to Sara's age, her mother continues to provide Sara's health history to the nurse. Which of the following actions by the nurse demonstrates that the nurse understands the importance of collecting a patient's health history? a) The nurse continues to collect information from Sara's mother knowing the informant will not always be the patient. b) The nurse explains to Sara's mother that the patient must be the primary informant while collecting the health history. c) Allow Sara's pediatrician to conduct the health history. The pediatrician can allow the child to participate in the assessment, as appropriate. d) Repeat the information back to Sara so that she can confirm that the information provided to the nurse by her mother is correct.
The nurse continues to collect information from Sara's mother knowing the informant will not always be the patient. Explanation: The informant, or the person providing the health history, may not always be the patient. The nurse assesses the reliability of the mother and the usefulness of the information provided. It is within the scope of the nurse to collect the health history.
The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis? a) high lymphocyte count b) low serum albumin levels c) high prealbumin level d) high transferrin levels
low serum albumin levels Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. In addition, transferrin levels decrease in response to protein depletion. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding.
The nurse determines the client's temperature, utilizing palpation by a) using the fingertips. b) using the surface of the palm. c) using the back of the hand. d) tapping a portion of the body.
using the back of the hand. Explanation: When palpating, the nurse uses the fingertips to detect pulsations or to differentiate surfaces, the surface of the palm to sense vibrations, and the back of the hand to determine the temperature. Percussion means tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures.
