Fundamentals Exam 1

Madeline Leininger formulated a theory that highlights what?

Nursing behaviors that are necessary to carry out an effective cultural assessment

Which sub-scale category is not part of the Braden Scale for Predicting Pressure Ulcer Risk?

Obesity

All but one of the following are types of nursing assessments. Which one does not belong?

Physical

A nurse is admitting a new patient. The patient is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the patient

A patient comes to the Emergency Department complaining of chest pain. This would be considered....

Subjective primary data

A nurse is interviewing a patient who uses a verbal expression with which the nurse is unfamiliar. What is the most appropriate way for the nurse to clarify the meaning of the expression with the patient?

Tell me what you mean by ________?

Skin turgor is best assessed by picking up a large fold of skin on ......

The anterior chest under the middle of the clavicle

Checking for skin temperature is best accomplished by using...

The dorsal surface of the hand

The nurse is conducting a physical assessment. The amount of data the nurse would collect can vary depending upon what important variable?

The patient's acuity

Which line is the primary reference for respiratory assessment of the posterior thorax?

The vertebral line

All but one item below gives an important reason for assessing vital signs. Identify the one that does not apply.

To improve a patient's condition

Mr. Smith is 60 years old and has been smoking an average of two packs of cigarettes a day since he was twelve. What is his pack years value?

96

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

What would the nurse expect to hear when auscultating the lungs of a client with inflammatory pleuritis?

A friction rub

Nevus or nevi is the medical term for....

A mole

When assessing the apices of the lungs, the nurse would locate them....

Above the clavicals

Your patient complains of severe abdominal pain. When further assessing this symptom, you would ask all of the following except which term?

Appearance

The ABCDE of melanoma detection includes all but which one of the following?

Birthmark

During an initial home visit, the patient's temperature is noted by the visiting nurse to be 99 degrees F. This temperature....

Cannot be evaluated without knowledge of the person's age

Upon entering the patient's room, the nurse observes the patient leaning forward with his arms supporting his body weight. What does she suspect as a likely Medical Diagnosis for this patient?

Chronic Obstructive Pulmonary Disease (COPD)

The nurse is admitting a 75 year old male with a 50 year history of smoking one pack of cigarettes a day. He is chronically short of breath. The nurse looks at his nails for....

Clubbing

A nurse performs a comprehensive assessment on a patient. Which of the following components is included only in a comprehensive assessment?

Complete health history

Values, beliefs and attitudes that influence the way people see and behave in the world is defined as...

Culture

A genogram is developed to visually show....

Family health patterns

When percussing the posterior thorax of the patient, the nurse hits the scapula. What sound will be heard?

Flatness

All of the following skin lesions are all papular except.....

Freckles

Unless there is an emergency, the lungs are typically assessed.....

From apex to base

Your patient is admitted with an asthma exacerbation. Which finding suggests her respiratory status is worsening?

Intercostal retractions

A patient says that his abdominal pain worsens when he ambulates. The nurse considers this to be indicative of...

An aggravating factor.

A nurse is admitting a patient who is scheduled to have cardiac bypass surgery in the morning. Assessment reveals that the patient is very anxious, and the nursing assistant reports that the patient's blood pressure is elevated. How would the nurse describe this patient's problem in order to plan interventions?

Anxiety related to pending bypass surgery as evidenced by increase in blood pressure and patient verbalizations

An elderly adult is admitted to the hospital with pneumonia. While performing the nursing admission assessment, the nurse finds a reddened area on the patient's coccyx. What descriptive item would the nurse omit in her documentation about this reddened area?

Depth

The MMSE is used to assess for severity of alterations in orientation, registration, attention, calculations, recall, and language. For which of the following patients would the MMSE be most appropriate?

For adults to assess for cognitive impairment

A student nurse is assigned to the behavioral health unit of a psychiatric hospital. While helping with an admission, the staff suggests the student should use the following tool to assess the new patient's spirituality. Which tool does the student use?

HOPE

Spiritually can be best described as...

Having to do with matters of the soul

Seeking understanding of patients' culturally based health care practices is essential to nursing because each culture has its own beliefs about health and illness and these beliefs....

May affect patient acceptance and adherence to the plan of care

A patient is admitted to the hospital with multiple trauma from a automobile accident. He was unconscious for several days in the ICU but is now improved and alert, and is transferred to your medical-surgical division. Which of the following lab results is the best indication of the patient's current nutritional status?

Prealbumin

A nurse is preparing to admit a new patient to the unit and is reviewing the patient record chronologically. In what phase of the interview process are the nurse and patient?

Preinteraction

An adult patient has a BMI of 14. Which nursing intervention is indicated?

Provide additional high protein, high calorie shakes

Parents bring a child to the pediatric clinic with a rash on her knee. On assessment the nurse notes the area to have reddish-pink lesions covered with silvery scales. What does the nurse suspect?

Psoriasis

Mallory, 16 years old, is having difficulty in school and with her friends. She has not decided what she wants to do in her life after high school. Erickson would say that Mallory is at risk for....

Role Confusion

A patient tells the nurse that he is sorry he fell of the roof and broke his leg. The nurse responds by saying, "Oh, you poor thing! I am so sorry you fell off the roof and broke your leg, too!" What type of response is this?

Sympathetic

Upon entering the adult patient's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

Systolic blood pressure of 180mm Hg

When auscultating the various lobes of the lungs, one is only assessed anteriorly. It is......

The right middle lobe

A nursing instructor is discussing the purposes of health assessment. What is the primary purpose of health assessment when done upon arrival in the hospital setting?

To establish a baseline database of objective and subjective data against which subsequent assessments can be measured

During an initial assessment of a new patient, the nurse observes that his weight is 210 pounds and his height is exactly 6 feet. What is this patient's BMI?

28.5