chapter 1,2,7 test questions

In the diagnostic process, what should immediately precede the step of identifying a list of possible nursing diagnoses?

Grouping assessment findings to identify commonalities Explanation: The diagnostic process progresses from assessment to identifying deviations from norms followed by group the data. Possible nursing diagnoses are then identified then confirmed or excluded.

Pain is whatever the patient says it is. Self-report is the gold standard for assessing pain; however, nurses learn when assessing pain to assess the following as well: (Check all that apply.)

• Grimacing • Rocking • Increased heart rate • Increased blood pressure

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose?

Make a clinical judgment

Program strategies consistent with a socioenvironmental approach to health and health promotion for nursing students would include:

Screening for occupationally induced physiological risk factors of disease Explanation: A priority of the socioenvironmental approach to health is the identification of factors in the workplace that may contribute to health problems.

In what area do nurses use formalized screening and assessment tools?

Skin breakdown Explanation: Nurses utilize many assessment tools. These tools are used in areas of prevention such as falls, malnutrition, and skin breakdown.

When clustering data, age can be a factor in determining the number of nursing diagnoses. The younger child typically has one diagnosis because he or she is more likely to have a single disease.

TRUE

During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following?

Analgesics Explanation: Analgesics are most often the primary treatment measure for pain, although a growing trend involves the integration of complementary, nonpharmacologic measures with conventional medicine.

A nurse has completed gathering some basic data about a client and then reflects on personal feelings about the client. The nurse does this primarily to accomplish which of the following?

Avoid biases and judgments

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:

Blood pressure Explanation: Blood pressure is a vital sign, not part of the general survey. Apparent age, signs of distress, and appearance are all parameters of the general survey.

How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data he or she collects?

By generating plans early Explanation: By generating plans early and testing them sequentially, experienced nurses improve their efficiency and enhance the relevance and value of the data they collect.

A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?

COMPREHENSIVE Explanation: This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.

In comparison with the physician's medical exam, the comprehensive health assessment performed by the nurse focuses on which aspect?

Effect of health on lifestyle Explanation: The comprehensive health assessment focuses on how the client's health status affects the activities of daily living and how the client's activities and choices affect the health status. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. In contrast, the physician performing a medical examination focuses primarily on the client's physiologic development status with less focus on psychological, sociocultural, or spiritual well-being.

Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

Evaluating orthostatic hypotension Explanation: For a client taking antihypertensive agents, the nurse should assess for possible orthostatic hypotension, which could increase the client's risk for falls. The blood pressure would fall with a change in position from lying to sitting or standing. A widening pulse pressure may be seen with aging.

The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

Integrates visual, auditory, and olfactory data Explanation: The general inspection integrates sights, smells, and sounds to form a preliminary sense of the client's status. Pain assessment and work environment are not part of the scope, and it is not necessary to position the client in a lying position at this stage

A nurse obtains a blood pressure on an elderly client of 160/70 mmHg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage I hypertension is a blood pressure reading of 140-159/90-99mmHg. Hypertension is not normal for any client.

A nurse is presenting an in-service program to a group of nurses who will be working on an oncology unit. Which of the following would the nurse include when describing cancer pain?

It is caused by compressed peripheral nerves. Explanation: Cancer pain is 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. It is not considered a chronic neuropathy. In addition, it does not necessarily occur in the first month after cancer develops. Acute pain is most commonly associated with a specific recent trauma. (

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

PATIENT'S ACUITY Data that nurses collect during a physical assessment vary depending on a client's acuity, health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms.

The nurse is using the Visual Analog Scale to assess pain of an adult patient. The nurse instructs the patient to

Place a mark on a 100-mm line with "no pain" at one end and "worst possible pain" at the other Explanation: The Visual Analog Scale is a 100-mm line with "no pain" at one end and "worst possible pain" at the other. The Numeric Pain Intensity Scale is a one-dimensional pain scale using an 11-poing Likert-type scale ranging from 0 to 10, where 0 means "no pain" and 10 means "worst possible pain." The Combined Thermometer Scale looks like a thermometer and has both numbers that increase from the bottom up and descriptor words to measure pain intensity. The Brief Pain Impact Questionnaire is a short questionnaire comprised of open ended questions to assess pain.

The nurse has identified several risk factors for a patient in the hospital that has fallen. Which step of the diagnostic reasoning process is the identification of these risk factors?

Step One--Identify Abnormal Data and Strengths Explanation: The nurse should have a basic knowledge of risk factors for the patient. Risk factors are based on patient data such as gender, age, ethnic access to both the data supplied by the patient and the known risk factors for specific diseases or disorders.

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:

Using reputable health-education strategies to reduce risk behaviors Explanation: A central component of health promotion involves helping clients to develop personal health practices and to enhance coping skills, which are results of health education that emphasizes client knowledge for directing choices and actions. While the other given factors may hold significance for many individuals, they are not as salient as health education

A patient with diabetes is admitted to the medical unit for the fifth time in 6 months because of elevated blood glucose level. The nurse caring for the patient immediately states, "I knew she would be back. It was just a matter of time. She is so noncompliant." This is an example of which of the following?

not hypothesizing several diagnoses Explanation: Nurses need to increase their diagnostic accuracy. Pitfalls decrease the reliability of cues and diagnostic accuracy. One pitfall is too many or too few data, unreliable data, and insufficient cues available. Other pitfalls are cues may be clustered yet unrelated. Another error is quickly diagnosing without hypothesizing. In this case the nurse states the patient is noncompliant because the same problem is recurring, but in actuality the patient may not have the sufficient knowledge or the means or funds to control the blood glucose level.

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

retake the bp

A nurse attempts to assess a client's pain but finds the client is having difficulty describing the pain. Which interventions by the nurse may help with the collection of subjective data about the client's pain? Select all that apply.

• Maintain a quiet and calm environment • Assure the client's privacy • Document the terms used by the client Explanation: To help the client describe the pain, the nurse should maintain a quiet and clam environment, maintain the client's privacy, ask questions in an open format, listen carefully to the client's verbal descriptions, watch for facial grimaces, and do not put words in to the client's mouth