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Nur 245 / Nur245 Exam 1. Questions With 100% Correct Answers.

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What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap? a. Diastolic blood pressure may not be heard. b. Diastolic blood pressure may be falsely low. c. Systolic blood pressure may be falsely low. d. Systolic blood pressure may be falsely high. ANS: C -If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension. When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement? a. MAP is the pressure of the arterial pulse. b. MAP reflects the stroke volume of the heart. c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle. d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion. ANS: C -MAP is the pressure that forces blood into the tissues, averaged over the cardiac cycle. Stroke volume is reflected by the blood pressure. MAP is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer; rather, it is a value closer to diastolic pressure plus one third of the pulse pressure. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have? a. Hypopituitary dwarfism b. Achondroplastic dwarfism c. Marfan syndrome d. Acromegaly ANS: A Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The childs appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood. (For more information, see Table 9-5, Abnormalities in Body Height and Proportion.) When checking for proper blood pressure cuff size, which guideline is correct? a. The standard cuff size is appropriate for all sizes. b. The length of the rubber bladder should equal 80% of the arm circumference. c. The width of the rubber bladder should equal 80% of the arm circumference. d. The width of the rubber bladder should equal 40% of the arm circumference. ANS: D The width of the rubber bladder should equal 40% of the circumference of the persons arm. The length of the bladder should equal 80% of this circumference. While measuring a patients blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply. a. The person supports his or her own arm during the blood pressure reading. b. The blood pressure cuff is too narrow for the extremity. c. The arm is held above level of the heart. d. The cuff is loosely wrapped around the arm. e. The person is sitting with his or her legs crossed. f. The nurse does not inflate the cuff high enough. ANS: A, B, D, E -Several factors can result in blood pressure readings that are too high or too low. Having the patients arm held above the level of the heart is one part of the correct technique. (Refer to Table 9-5, Common Errors in Blood Pressure Measurement.) When assessing the intensity of a patients pain, which question by the nurse is appropriate? a. What makes your pain better or worse? b. How much pain do you have now? c. How does pain limit your activities? d. What does your pain feel like? ANS: B -Asking the patient how much pain do you have? is an assessment of the intensity of a patients pain; various intensity scales can be used. Asking what makes ones pain better or worse assesses alleviating or aggravating factors. Asking whether pain limits ones activities assesses the degree of impairment and quality of life. Asking what does your pain feel like assesses the quality of pain. During assessment of a patients pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. a. Sleeping b. Moaning c. Diaphoresis d. Bracing e. Restlessness f. Rubbing A,D,F The nurse needs to assess a patients ability to perform activities of daily living (ADLs) and should choose which tool for this assessment? a. Direct Assessment of Functional Abilities (DAFA) b. Lawton Instrumental Activities of Daily Living (IADL) scale c. Barthel Index d. Older Americans Resources and Services Multidimensional Functional Assessment QuestionnaireIADL (OMFAQ-IADL) An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? a. Lawton IADL instrument b. Hospital Admission Risk Profile (HARP) c. Mini-Cog d. NEECHAM Confusion Scale -Hospital-acquired functional decline may occur within 2 days of a hospital admission. The HARP helps identify older adults who are at greatest risk of losing their ability to perform ADLs or mobility at this critical time. The Lawton IADL measures instrumental activities of daily living, which may be difficult to observe in the hospital setting. The Mini-Cog is an assessment of mental status. The NEECHAM Confusion Scale is used to assess for delirium.

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NUR 245 EXAM 1
During a class on the aspects of culture, the nurse shares that culture has four basic
characteristics. Which statement correctly reflects one of these characteristics?
a. Cultures are static and unchanging, despite changes around them.
b. Cultures are never specific, which makes them hard to identify.
c. Culture is most clearly reflected in a persons language and behavior.
d. Culture adapts to specific environmental factors and available natural resources.




When discussing the use of the term subculture, the nurse recognizes that it is best
described as:
a. Fitting as many people into the majority culture as possible.
b. Defining small groups of people who do not want to be identified with the larger
culture.
c. Singling out groups of people who suffer differential and unequal treatment as a
result of cultural variations.
d. Identifying fairly large groups of people with shared characteristics that are not
common to all members of a culture.

,The nurse manager is explaining culturally competent care during a staff meeting.
Which statement accurately describes the concept of culturally competent care?
The caregiver:
a. Is able to speak the patients native language.
b. Possesses some basic knowledge of the patients cultural background.
c. Applies the proper background knowledge of a patients cultural background to
provide the best possible health care.
d. Understands and attends to the total context of the patients situation.




The nurse recognizes that an example of a person who is heritage consistent would
be a:
a. Woman who has adapted her clothing to the clothing style of her new country.
b. Woman who follows the traditions that her mother followed regarding meals.
c. Man who is not sure of his ancestors country of origin.
d. Child who is not able to speak his parents native language.




The nurse is conducting a heritage assessment. Which question is most appropriate
for this assessment?
a. What is your religion?
b. Do you mostly participate in the religious traditions of your family?
c. Do you smoke?

,d. Do you have a history of heart disease?




. Illness is considered part of life’s rhythmic course and is an outward sign of
disharmony within. This statement most accurately reflects the views about illness
from which theory?
a. Naturalistic
b. Biomedical
c. Reductionist
d. Magicoreligious




. The nurse recognizes that working with children with a different cultural perspective
may be especially difficult because:
a. Children have spiritual needs that are influenced by their stages of development.
b. Children have spiritual needs that are direct reflections of what is occurring in
their homes.
c. Religious beliefs rarely affect the parents perceptions of the illness.
d. Parents are often the decision makers, and they have no knowledge of their
children’s spiritual needs.

, After a symptom is recognized, the first effort at treatment is often self-care. Which
of the following statements about self-care is true? Self-care is:
a. Not recognized as valuable by most health care providers.
b. Usually ineffective and may delay more effective treatment.
c. Always less expensive than biomedical alternatives.
d. Influenced by the accessibility of over-the-counter medicines.




Which of the following reflects the traditional health and illness beliefs and practices
of those of African heritage? Health is:
a. Being rewarded for good behavior.
b. The balance of the body and spirit.
d. Maintained by wearing jade amulets.




The nurse is reviewing aspects of cultural care. Which statements illustrate proper
cultural care? Select all that apply.
a. Examine the patient within the context of ones own cultural health and illness
practices.
b. Select questions that are not complex.
c. Ask questions rapidly.
d. Touch patients within the cultural boundaries of their heritage.
e. Pace questions throughout the physical examination.

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