NUFT 202 Exam 2 Questions with Answers

NUFT 202 Exam 2 Questions with Answers which of the following examples are steps of the nursing assessment? 1. collection of information from patients family members 2. recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. complete documentation of observational information 5. Determining which medications to administer based on a patients assessment data - Answer-1, 2, 3 A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's func- tional health patterns? 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern -Answer-4- health perception-health management pattern When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) 1. An observation of how a patient turns and moves in bed 2. The unit policy and procedure manual 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film 5. Your experiences in caring for other patients with similar problems -Answer-1,3,4 The unit policy/ procedure manual is not used to collect data about a patient. While experience caring for other patients with similar problems may help guide a nurses assessment, data about a particular patient does not come from those prior experiences. The nurse observes a patient walking down the hall with a shuf- fling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the infor- mation gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Cue. 2. Reflection. 3. Clinical inference. 4. Probing. -Answer-3- A cue is information you obtain through your senses (the nurse observes the patient walking with a shuffling gait). A clinical inference is the nurse's judgment or interpretation of these cues (the conclusion that the patient has a mobility problem).Reflection and probing are not relevant to this example. A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1. Review of systems approach 2. Use of a structured database format 3. Back channeling 4. A problem-oriented approach -Answer-4- a problem oriented approach comes from caring for patients in immediate pain The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data validation 4. Termination -Answer-2- working phase allows patients to describe their concerns and problems A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? 1. "I can tell that your eating habits have led to your diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish patients understood how overeating affects their health." -Answer-3 This is the only assessment approach that is not biased or does not show judgment about the patient's weight or occupational status. With the other options, the nurse is reacting to the patient on the basis of personal stereotypes and biases. Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? 1. Probing 2. Open-ended 3. Problem-oriented 4. Confirmation -Answer-2- open ended allows for the patient to tell a story and explain their purpose for seeking care A nurse gathers the following assessment data. Which of the fol- lowing cues together form(s) a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Patient has a heart rate of 78 beats/min and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is 38.3° C (101° F). 6. Patient states, "I'm worried that I won't be able to return to work when I planned." -Answer-1,4,5- these cues suggest that their is problems with the patient that needs assessing A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Patient's level of function. 2. Patient's willingness to perform self-care. 3. Patient's level of consciousness. 4. Patient's health management values. -Answer-1- patients able to perform any activities can determine their level of function A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and