Chapter 5 Prep U

Why should the nurse to be empathetic when caring for a client?

nurse to be empathetic when caring for a client? Empathy helps the nurse become effective while remaining detached.

Which observation made by the nurse reflects the first fundamental technique used in physical examination?

"Patient appears older than stated age."

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?

99.6 degrees F

Which statement made by the nurse would be a nontherapeutic response when the patient says, "I will not take pain medication when I am in pain"?

"Refusing medication can only hurt you by increasing your awareness of the pain experience."

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?

60 minutes per day

The nurse assesses the patient's posture, stature, and body movements. What part of the physical examination process is this?

Inspection

A hospice nurse is discussing spirituality and faith with a client and the client's family member. The client asks the nurse what is the difference between spirituality and faith. How will the nurse describe faith?

"A trust and belief in a higher power or something you cannot see"

Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures?

Liver

A female patient comes to the clinic for evaluation. As part of the assessment, the nurse determines the patient's ideal body weight. The patient is 5' 5" tall and has an average frame. What would be her ideal body weight in lbs? Enter the correct number only.

125 lbs

A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk?

23

The nurse is discussing lifestyle changes and weight reduction with a female patient who has excess abdominal fat. What waist circumference should the patient maintain in order to remain healthy?

30 to 34 inches (76 to 86 cm)

An individual is considered obese when their BMI is what value?

30-39

A nurse determines that a male patient has an increased risk for diabetes, heart disease, and hypertension based on the patient's waist circumference. Which waist circumference measurement would lead the nurse to suspect this?

41 inches

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?

5

A new client walking in to the health care center is actively wheezing and reports frequent episodes of wheezing. Based on the client's responses during the interview, the nurse suspects the client has a variety of food allergies. What nutritional assessment method should the nurse include in the plan of care?

A 3- to 7-day food record

A positive nitrogen balance indicates which condition?

Tissue growth

Which area for assessing the client profile should be addressed last?

"What do you usually do for fun?"

Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history?

"How has the stroke affected your ability to perform your daily activities?"

A graduate nurse is completing her first health history questionnaire with a client. She needs to assess the client's sexual history at the end of the interaction. Which opening remark for this topic would be most appropriate?

"Lastly, I need to ask about your sexual health and practices."

A nurse cares for an older adult client who is taking over ten different medications or supplements. What statement made by the nurse best assesses the client for medication interactions?

"Can you please tell me what each of your medications are for?"

Which statement by the nurse reflects the nurse's attempt to establish rapport and reduce patient anxiety?

"Good morning, Mr. Jones. The last time you were here you were planning a vacation. Tell me about your trip."

Which question would help the nurse gather information about a client's lifestyle that may be a factor in the client's present illness?

"How many cups of coffee do you drink each day?"

A nurse is preparing to obtain the health history of an older adult client. Which question posed by the nurse best focuses the clinical evaluation of the older adult client?

"What interferes most in your daily activities?"

A waist circumference greater than which value is indicative of excess abdominal fat in men?

101.60 cm (40 in)

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?

"You seem upset about the pain. Tell me what's happening."

To calculate the ideal body weight for a woman, the nurse allows for which of the following?

100 lb for 5 ft of height

What primary nutritional nursing consideration should be included in the physical assessment of an older adult patient?

Altered metabolism and nutrient use secondary to an acute or chronic illness

Nursing students are reviewing information about the MyPyramid recommendations for food intake. The students demonstrate a need for additional review when they identify which of the following as one of the five major food groups?

Fats

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?

Auscultation

A nurse determines that a patient has poor nutrition based on which assessment finding?

Beefy-red tongue

Which is the last area to be addressed when assessing the client profile?

Body image

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?

Check to make sure that the patient has his hearing aid turned on and in place in his left ear.

When taking a health history, which of the following would most likely be the primary source of information?

Client

While collecting the client profile information, the client admits to crying everyday after working 8 hours in a factory. This finding reflects what part of the profile?

Coping strategies

When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard?

Dull sound

During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches (98 cm). Based on this finding, which of the following is a priority intervention?

Educate the client regarding her increased risk for hypertension and diabetes.

Which factor is important for the nurse to consider during the pre-interview period with an adult client?

Establish rapport with the client and family members

What priority factor regarding the patient may help the physician arrive at a diagnosis?

History of the present illness

A student nurse walks into a client's room and observes the client chanting and holding his rosary. The client pauses and asks the student nurse to join hands while he prays. What is the best action for the student nurse to take?

Join hands with the client and remain at the bedside until the patient finishes the prayer.

While assessing a client's abdomen, the nurse percusses a dull sound, not the expected tympany. Upon further reflection, the nurse realizes she has assessed what?

Liver

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?

Liver disease

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?

Losing a spouse and only child in an accident 2 months ago

A nurse is documenting a patient's chief complaint/reason for seeking care in the medical record. Which of the following would be MOST appropriate?

My head feels like it is about to explode."

Hyperresonance is audible when which area is percussed?

Overinflated lung tissue

The nurse notes hyperresonance over inflated lung tissue when performing a physical assessment on a patient with emphysema. What process does the nurse use for this assessment?

Percussion

Which method of physical examination refers to the translation of physical force into sound?

Percussion

During a physical examination, the nurse finds that a client has thin, dry hair with flaky skin, recessed gums, and ridged, brittle nails. The nurse can conclude what from these data?

Poor nutritional status

The nurse using the assessment technique depicted in the accompanying image realizes that the following factor most strongly influences the success of the results:

Quick striking

A client with chronic obstructive pulmonary disease (COPD) visits the health care center with breathing difficulties. It is observed that during coughing bouts, the client sits up in a tripod position to breathe. During inspection, the nurse notes that the client has developed a barrel-shaped chest. Which part of the client profile relates to the client's view of himself or herself and the impact of COPD?

Self-concept

During a physical examination of a client, in which situation is the nurse most likely to use the assessment technique that translates the application of physical force into sound?

The client who presents with a respiratory rate of 22 and a productive cough and reports shortness of breath when climbing stairs

The nurse is preparing the client file for an 8-year-old child. The child's mother informs the nurse that the child has difficulty breathing at night and makes a whistling sound while sleeping. Because of the child's age, her mother continues to provide the child's health history to the nurse. Which action by the nurse demonstrates that the nurse understands the importance of collecting a client's health history?

The nurse continues to collect information from the child's mother, knowing the informant will not always be the client.

The nurse observes that a client's medical report indicates that the client has Cushing syndrome. During inspection, the nurse notes that the client's BMI is 31, waist circumference is 40 inches, and localized fat pads exist around the neck and upper part of the back. Which of the following must the nurse keep in mind while planning the client's care?

The nurse recognizes that the client's obesity may be specifically related to the endocrine disorder. The nurse performs a thorough nutritional assessment.

During the initial physical examination, a client's pulse rate was 71 beats per minute (bpm). Four hours later on reassessment, the pulse rate was 40 bpm. How should the nurse proceed?

Thoroughly assess the client; then notify the physician.

When examining a patient's abdomen, the nurse percusses over the stomach. Which of the following would the nurse expect to elicit?

Tympany

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?

low serum albumin levels

At which body mass index (BMI) value are patients considered to have increased risk for problems associated with poor nutritional status?

lower than 18.5

The nurse determines the client's temperature through palpation by:

using the back of the hand.

Which question asked by the nurse will provide information about a patient's lifestyle? (Select all that apply.)

• "Do you have any food preferences?" • "How many hours of sleep do you require each day?" • "What type of exercise do you prefer?"

When obtaining a health history from a patient, what should be the nurse's primary focus? (Select all that apply.)

• A comprehensive body systems review • Current and past medical problems • Family history

When obtaining a health history from an older adult patient, what should the nurse remember to do? (Select all that apply.)

• Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. • Clarify the frequency, severity, and history of signs and symptoms of the present illness. • Conduct the interview in a calm, unrushed manner using eye-to-eye contact.

A community health nurse goes on a first home visit to complete a home safety assessment. Which of the following components will be part of the nurse's home safety assessment? Select all that apply.

• Hard wood floors in the dining room • Motion light on the porch • ABC fire extinguisher in the kitchen pantry

What does the patient have the right to know about the data collected by the nurse? (Select all that apply.)

• How the information will be used • Why the information is being obtained • Whether the information will be held in confidence

A very thin woman seeks medical care. During assessment of this client, the nurse determines the need for a nutritional assessment. Which of the following components will the nurse include in this assessment? Select all that apply.

• Ratio of body weight and height • Oral mucosa • Thyroid gland