Midterm Exam Flashcards
(137 cards)
Which adjustment in the physical environment should the nurse make to promote the success of an interview?
The nurse should secure a quiet environment, turning off distractions such as the TV or Radio. Pt and nurse should be 4-5ft apart in a well lit room with equal status seating and eye level.
During an assessment of a patient’s family history, the nurse constructs a genogram. What is a genogram?
A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings).
he nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
Health promotion refers to activities that promote a person’s health. For a man that includes the performance of testicular self-examinations.
What is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting?
The most important step to decrease the risk for microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed.
When would you use Standard Precautions in the health care setting?
Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status.
What information obtained by the nurse regarding a patient’s skin should the nurse record in the patient’s health history?
Anything that is subjective, such as patient denies any color change, whatever the person says about him or herself. Objective data would be location, size etc-anything that the nurse observed.
When checking for proper blood pressure cuff size, what is the guidance?
The width of the rubber bladder should equal 40% of the circumference of the person’s arm. The length of the bladder should equal 80% of this circumference.
Which technique is correct when the nurse is assessing the radial pulse of a patient?
a. Palpate for 10 seconds and multiply by 6, if the rhythm is regular and the patient has no history of cardiac abnormalities.
b. Palpate for 15 seconds and multiply by 4, if the rhythm is regular.
c. Palpate for 2 full minutes to detect any variation in amplitude.
d. Palpate for 1 minute, if the rhythm is irregular.
Palpate for 1 minute, if the rhythm is irregular.
Research suggests that the 30-second interval multiplied by 2 is a more accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular, then the 15-seconds interval multiplied by 4 as any one beat error in counting results in an error of 4 beats/minute. If the rhythm is irregular, then the pulse is counted for 1 full minute.
When planning a cultural assessment, the nurse should include which component?
Health-related beliefs and practices are one component of a cultural assessment.
During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating “the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society” reflects which term?
The culture that develops in any given society is unique, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society.
What are norms?
Norms refer to the typical or normal
What is ethnicity?
Ethnicity refers to a social group that may possess shared traits, such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences.
What is assimilation?
Assimilation refers to taking on the characteristics of the dominant culture.
he nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one’s spirituality?
a. Attendance at a specific church or place of worship
b. Belief in and the worship of God or gods
c. A connection with something larger than oneself and belief in transcendence
d. Being closely tied to one’s ethnic background
Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Belief in and the worship of God or gods and attendance at a specific church or place of worship apply to religion. Being closely tied to one’s ethnic background is not a concept of spirituality or religion.
The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take?
a. Ask the patient to read her health record and indicate any changes since her last visit.
b. Check the patient’s blood pressure.
c. Obtain a complete health history on the patient before checking her blood pressure.
d. Collect a follow-up database and then check the patient’s blood pressure.
Collect a follow-up database and then check the patient’s blood pressure.
What is a general survey?
The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior. Interpreting subjective data is not part of the general survey.
Measuring the patient’s vital signs (temperature, pulse, respirations, and blood pressure) and observing specific body systems while performing a physical assessment are part of the physical examination, not the general survey.
A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of assessment data is this?
Subjective data is what the person says about him or herself during history taking.
What is objective data?
Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
a. Severely abnormal vital signs
b. Low self-esteem
c. Lack of knowledge
d. Abnormal laboratory values
d. Abnormal laboratory values
Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security).
What are third-level priority problems?
Low self-esteem and lack of knowledge are considered third-level priority as although they are important to a patient’s health, they can be addressed after more urgent health problems are addressed
What data should the nurse collect during the interview portion of a health assessment?
Subjective
The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data; that is, what the person says about him or herself.
What type of data is collected during the physical portion of the health assessment?
Physical data/Objective Data
During an interview, the nurse states, “You mentioned having shortness of breath. Tell me more about that.” Which verbal skill is used with this statement?
Open-ended question
Why should a nurse used open ended questions?
Open-ended questions ask for narrative information and give the patient free rein. They state the topic to be discussed but only in general terms, which is what the statement in this question does.
