Module 2 Exam: HESI VN TXGRP 1912 COHORT (VNE 39) Quiz Score: 89.5 out of 99

Module 2 Exam: HESI VN TXGRP 1912 COHORT (VNE 39) Quiz Score: 89.5 out of 99 Question 1 1 / 1 pts A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? The client appears anxious. Blood pressure is 170/80 mm Hg. Correct! The client states that he has a rash. The client has diminished reflexes in the legs. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that include data that the nurse would obtain during the physical examination. Review the difference between subjective and objective data if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam information does the nurse recognize as objective data? The client is allergic to strawberries. The last menstrual period was 30 days ago. The client takes acetaminophen (Tylenol) for headaches. Correct! A 1 × 2-inch scar is present on the lower right portion of the abdomen. Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that include data that the nurse would obtain from the client during the health history. Review the difference between subjective and objective data if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Episodic Follow-up Emergency Correct! Complete Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting, such as a pediatric or family practice clinic; an independent or group private practice; a college health service; a women’s health care agency; a visiting nurse agency; or a community health agency. An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or one body system. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “initial home visit” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam and cough. The nurse should assist with the data collection by collecting which information? Data related to follow-up care A complete (total health) database Correct! Data related to the respiratory system Data related to the treatment for the cold Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Collect health history information first, then perform the physical examination. Correct! Ask health history questions while performing the examination and initiating emergency measures. Collect all information requested on the history form, including social support, strengths, and coping patterns. Perform emergency measures and not ask any health history questions until the client’s fractures have been treated in the operating room. Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client's immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note the strategic words “alert and cooperative.” Noting that the client has not sustained life-threatening injuries will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Question 6 1 / 1 pts A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? Emergency Correct! Follow-up Complete (total) Problem-centered Rationale: A follow-up database is compiled to evaluate the status of an identified problem at regular and appropriate intervals. An emergency database calls for rapid collection of the data, often at the same time lifesaving measures are being performed. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. An episodic database (problem-centered) is compiled for a limited or short-term problem. It is focused mainly on one problem or body system. Test-Taking Strategy: Focus on the data in the question. Noting the strategic words “at the clinic for a checkup” in the question will direct you to the correct option. Review the different types of databases if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment? Confirm the medical diagnosis. Make accurate nursing diagnoses. Identify any hereditary traits related to the epilepsy. Correct! Determine what the client believes has caused the epilepsy. Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis. Test-Taking Strategy: Use knowledge of the subject, Mexican American cultural beliefs, to begin the process of elimination. Eliminate the option that indicates to confirm a medical diagnosis because this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to the correct option. Review the nurse’s role in data collection and cultural considerations if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Cultural Diversity Question 8 1 / 1 pts A nurse assisting with data collection uses the back of the hand to feel the client’s skin on both arms and notes that the skin is warm. The nurse makes which determination? The client has a fever. Correct! The skin temperature is normal. The client needs to drink additional fluids. The client needs to have the blanket removed. Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own hands, then use the backs (dorsa) of the hands to palpate the client’s skin bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this finding. Test-Taking Strategy: Focus on the data in the question. Note the strategic word “warm.” Recalling that warmth suggests normal circulatory status will direct you to the correct option. Review normal skin temperature if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary A nurse assisting with data collection notes that the client’s skin is very dry. The nurse documents this finding using which term? Correct! Xerosis Pruritus Seborrhea Actinic keratoses