Chapter 1-15

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan."

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

"Nurses focus on the diagnosis of actual human responses to disease or life events."

_______________(small-diameter, lightly myelinated fibers) and ___________(unmyelinated, primary afferent fibers) are classified as nociceptors because they are stimulated by noxious stimuli.

A-delta primary afferent fibers c fibers

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

what intervention should a nurse implement to become culturally competent when assessing a client from another culture

Collect relevant cultural data of client's health history

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness

What action is appropriate for a nurse to perform when an irregular radial pulse is palpated on a client?

Count the pulse for a full minute for an accurate rate

The belief that the behaviors and practices of people should be judged only from the context of their cultural system.

Cultural relativism

The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data?

Follows a Kosher diet

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Formation of judgments that may interfere with the interview

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?

Identify in what areas the patient needs the most care

defined by its high resistance to pain relief

Intractable pain

The nurse is working with a client on how to manage his hypertension. The client states that he is taking herbs recommended from within his community. How should the nurse best respond

Let's talk with your physician to see how we an incorporate these into your plan of care.

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?

Mobile phones should only be used if there is a hands-free option available.

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan

Nursing process

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessemt on a client who is complaining of shortness of breath.

The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?

The new mother may believe buying infant clothing before the delivery is bad luck.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure >90 but <120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?

When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature.

transmit fast pain to the spinal cord within 0.1 second, which is felt as a pricking, sharp, or electric-quality sensation and usually is caused by mechanical or thermal stimuli.

a-delta primary afferent fibers

the circumstance when a person gives up the traits of his or her culture of origin as a result of context with another culture, to variable degrees.

acculturation

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for

acromegaly

usually associated with a recent injury

acute pain

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

ashen

the gradual adoption and incorporation of characteristics of the prevailing culture.

assimilation

refers to the verbal and nonverbal behaviors that the patient demonstrates in response to the pain.

behavioral dimension

A nurse assesses a 4-year-old boy who experiences gas, a stomachache, and diarrhea after consuming lactose products. The nurse recognizes the data as what type of biological variation?

biochemical

The client comes to the health care provider stating he has a sore throat and believes he needs an antibiotic. This is an example of of what type of model for health?

biomedical

Which of the following statements is true about biologic variation

both genetics and environment produce biologic variation

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

bruit

transmit slow pain within 1 second, which is felt as burning, throbbing, or aching and is caused by mechanical, thermal, or chemical stimuli, usually resulting in tissue damage.

c fibers

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

c7

often due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration

cancer pain

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

characteristic symptoms

usually associated with a specific cause or injury and described as a constant pain that persists for more than 6 months

chronic nonmalignant pain

nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?

clustered

concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management" (p. 14). Of course, beliefs, attitudes, intentions, and motivations are affected by all of the dimensions mentioned, but can be associated with the management part of the pain experience, which is dependent on cognition.

cognitive dimension

the nurse is caring for a patient who is from another country, and states to the charge nurse, "I just don't know if the patient really understands what I am saying, and I am not understanding the patient either, even though he speaks English." What stage of cultural awareness is the nurse experiencing?

conscience incompetence

in preparing a care plan for a patient receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?

constipation

The "evil eye" is an example of what

cultural bound syndrome

A male nurse is caring for an elderly woman who has become withdrawn and somewhat confused since the nurse has come on duty. When the nurse goes into the room to bathe the patient, she refuses to allow it. The best explanation for her actions would be which of the following?

cultural differences

`The co-existence of a difference in behavior, traditions, and customs—in short, a diversity of cultures, often resulting from cross-border population flows; perhaps better referred to as "cultural pluralism

cultural diversity

The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making

culture

ligaments, tendons, bones, blood vessels, nerves

deep somatic pain

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis

The nurse spends a day off in a part of a non-English speaking community in order to learn more about the culture to improve interactions when providing client care. What cultural activity is this nurse demonstrating?

desire

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing

domestic abuse

A nurse is assessing a client before administration of an antibiotic. The nurse should be aware that which of the following represents a biochemical variation that may exist between clients of different cultures?

drug metabolism

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

empathy

A natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one's culture through socialization.

enculturation

A socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come into contact

ethnicity

The universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways.

ethnocentrism

Stereotyping is defined as

expecting all members of a cultural group to hold the same beliefs and behave in the same

The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the patient's pain, what is the most appropriate pain assessment tool for the nurse to use?

faces pain scale

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment.

The result of a nursing assessment is the

formulation of nursing diagnoses.

A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in this client

ghost sickness

What is the most common type of hyperthyroidism?

graves disease

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

injuries to head and neck

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances.

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

migraine

a patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain

neuropathic

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

ongoing

can be perceived in nerves left by a missing, amputated, or paralyzed body part.

phantom pain

can be perceived in nerves left by a missing, amputated, or paralyzed body part.

physical dimension

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

primary

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

pustular acne

concerns the quality of the pain and how severe the pain is perceived to be. This dimension includes the patient's perception of the pain's location, intensity, and quality.

sensory dimension

concerns the influences of the patient's social context and cultural background on the patient's pain experience.

sociocultural dimension

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?

somatic pain

______________of pain begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage stimulating the nociceptors, which are the primary afferent nerves for receiving painful stimuli.

transduction

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

trigeminal neuralgia.

Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing?

visceral pain

A patient from the Middle East has been referred to the mental-health clinic believes that he is possessed by a spirit and has been for many years. The patient has been withdrawn and is not eating. What does the nurse understand that this patient may be experiencing?

zar

A client comes to the ED with lower abdominal pain. She is extremely emotional and moving wildly on the gurney. A nurse says to another nurse that the client is "way overdoing it." What action should the nurse take to best provide care for this client?

Conduct a cultural assessment to better understand the client's perception of pain and illness.

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing or partial

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment

To determine any changes from the baseline data

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash

Urticaria or hives

A client presents to the health care clinic with reports of a 2-day history of sore throat, ear pressure, fever, and stiff neck. The client states she has taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

acute pain related to sore throat

concerns feelings, sentiments, and emotions related to the pain experience. The pain can affect the emotions and the emotions can affect the perception of pain.

affective dimension

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are caused by

aging

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

airway

A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?

give the prn morphine

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

hyperthyroidism

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

macule

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules

Which of the following is the best example of assessment in everyday life?

measuring the remaining tread on a car tire to determine whether it is time to replace it

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

meningitis

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?

neuropathic pain

The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

node is fixed and rubbery

The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan

nutritional information specifically for the client's culture.

refers to the meaning and purpose that the person "attributes to the pain, self, others, and the divine" (p. 15). For some suggested questions to assess each dimension, see Assessment Guide 9-1.

spiritual dimension

An oversimplified conception, opinion, or belief about some aspect of an individual or group.

stereotyping

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

sternocleidomastoid

When assessing the client for pain, the nurse should believe the client when he or she claims to be in pain? T OR F

t