Exam II: "Nursing Process" (Fundamentals of Nursing/NURS9108, NWACC) Exam With Complete Solutions

Exam II: "Nursing Process" (Fundamentals of Nursing/NURS9108, NWACC) Exam With Complete Solutions Q: Which of the following examples are steps of nursing assessment? (Select all that apply) 1. Collection of information from patient's 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 patient's assessment data. (Question 1 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: 1, 2, 3. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224) Q: 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 functional health patterns? a. Value-belief pattern b. Cognitive-perceptual pattern c. Coping--stress-tolerance pattern d. Health perception-health management pattern (Question 2 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: (d.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224) Q: 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. (Question 3 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: 1, 3, 4. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224) Q: The nurse observes a patient walking down the hall with a shuffling gate. When the patient returns to bed, the nurse checks the strength of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: a. Cue b. Reflection c. Clinical inference 4. Probing (Question 4 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: (c.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224) Q: 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? a. Review of systems approach. b. Use of a structured database format. c. Back channeling. d. A problem-oriented approach. (Question 5 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: (d.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224) Q: 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? a. Orientation b. Working phase c. Data validation d. Termination (Question 6 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: (b.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)** Q: A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2kg (300lbs), 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? a. "I can tell that your eating habits have lead to your diabetes. Is that right?" b. "It's been difficult for people to find jobs. Is that why you work part time?" c. "You nave four children; do you have any concerns about going home and caring for them?" d. "I wish patients understood how overeating affects their health." (Question 7 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223]) - answerA: (c.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224) Q: Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? a. Probing b. Open-ended c. Problem-oriented d. Confirmation