NSG 3160 Exam 1 Questions With Complete Solutions
A common error in blood pressure measurement is
a. waiting less than 1 to 2 minutes before repeating the blood
pressure reading on the same arm.
b. taking the blood pressure in an arm that is at the level of the
heart.
c. deflating the cuff about 2 mm Hg per heartbeat.
d. using a blood pressure cuff whose bladder length is 80% of
the arm circumference. Correct Answers a. waiting less than 1
to 2 minutes before repeating the blood pressure reading on the
same arm.
Waiting less than 1 to 2 minutes before repeating the blood
pressure reading on the same arm will result in a falsely high
diastolic pressure r/t venous congestion in the forearm. The
patient's arm should be positioned at the level of the heart when
obtaining a blood pressure measurement. The cuff should be
deflated at a rate of 2 mm Hg per heartbeat. The blood pressure
cuff bladder length should be about 80% of the arm
circumference.
A complete database is
a. used to collect data rapidly and is often compiled concurrently
with lifesaving measures.
b. used to evaluate the cause or etiology of disease.
c. used for a limited or short-term problem usually consisting of
one problem, one cue complex, or one body system.
,d. used to perform a thorough or comprehensive health history
and physical examination. Correct Answers d. used to perform
a thorough or comprehensive health history and physical
examination.
A complete database includes a complete health history and a
full physical examination; it describes the current and past
health state and forms a baseline against which all future
changes can be measured. An emergency database is a rapid
collection of data often obtained concurrently with lifesaving
measures. A focused database is for a limited or short-term
problem; this database concerns mainly one problem, one cue
complex, or one body system. Medical diagnoses are used to
evaluate the cause or etiology of the disease.
A nurse precepting a student nurse asks, "What's the most
important step in the critical-thinking process?"
a. Clustering subjective and objective data
b. Analyzing health data
c. Using evidence-based assessment techniques
d. Prioritizing health concerns Correct Answers c. Using
evidence-based assessment techniques
Evidence-based techniques are supported by research showing
effectiveness of the technique that provides the safest and most
current techniques to promote the health of patients. Clustering
subjective and objective data is a step in the critical-thinking
process, but is not the most important step. Analyzing health
data is a step in the critical-thinking process, but is not the most
,important step. Prioritizing health concerns is a step in the
critical-thinking process, but is not the most important step.
A patient admitted to the hospital with asthma has the following
problems identified based on an admission health history and
physical assessment. Which problem is a first-level priority?
a. Ineffective self-health management
b. Impaired gas exchange
c. Readiness for enhanced spiritual well-being
d. Risk for infection Correct Answers b. Impaired gas
exchange
First-level priority problems are problems that are emergent,
life-threatening, and immediate. Impaired gas exchange is an
emergent and immediate problem. Third-level priority problems
are problems that are important to the patient's health but can be
addressed after more urgent health problems are addressed.
Ineffective self-health management is an example of a third-
level priority. Second-level priority problems are problems that
are next in urgency; these problems require prompt intervention
to forestall further deterioration. Risk for infection is an example
of a second-level priority. Third-level priority problems are
problems that are important to the patient's health but can be
addressed after more urgent health problems are addressed.
Wellness diagnoses are third-level priority problems.
A patient seeks care for "debilitating headaches that cause
excessive absences at work." On further exploration, the nurse
asks, "What makes the headaches worse?" With this question,
the nurse is seeking information about
, a. the patient's perception of pain.
b. the nature or character of the headache.
c. relieving factors.
d. aggravating factors. Correct Answers d. aggravating factors.
Aggravating factors are determined by asking the patient what
makes the pain worse. To determine the patient's perception of
pain, the nurse would determine the meaning of the symptom by
asking how it affects daily activities and what the patient thinks
the pain means. The nature or character calls for specific
descriptive terms to describe the pain. Relieving factors are
determined by asking the patient what relieves the pain, what is
the effect of any treatment, what the patient has tried, and what
seems to help.
A woman seeks medical attention for a cut made by a knife
during a physical assault. The health care provider would
document the cut as an
a. incision.
b. ecchymosis.
c. avulsion.
d. abrasion. Correct Answers a. incision.
An incision is a cut or wound made by a sharp instrument.
Ecchymosis is a hemorrhagic spot or blotch in the skin or
mucous membrane that forms a non-elevated, rounded or
regular, blue or purplish patch. An avulsion is the tearing away
of a structure or part. An abrasion is a wound caused by rubbing
the skin or mucous membrane.
A common error in blood pressure measurement is
a. waiting less than 1 to 2 minutes before repeating the blood
pressure reading on the same arm.
b. taking the blood pressure in an arm that is at the level of the
heart.
c. deflating the cuff about 2 mm Hg per heartbeat.
d. using a blood pressure cuff whose bladder length is 80% of
the arm circumference. Correct Answers a. waiting less than 1
to 2 minutes before repeating the blood pressure reading on the
same arm.
Waiting less than 1 to 2 minutes before repeating the blood
pressure reading on the same arm will result in a falsely high
diastolic pressure r/t venous congestion in the forearm. The
patient's arm should be positioned at the level of the heart when
obtaining a blood pressure measurement. The cuff should be
deflated at a rate of 2 mm Hg per heartbeat. The blood pressure
cuff bladder length should be about 80% of the arm
circumference.
A complete database is
a. used to collect data rapidly and is often compiled concurrently
with lifesaving measures.
b. used to evaluate the cause or etiology of disease.
c. used for a limited or short-term problem usually consisting of
one problem, one cue complex, or one body system.
,d. used to perform a thorough or comprehensive health history
and physical examination. Correct Answers d. used to perform
a thorough or comprehensive health history and physical
examination.
A complete database includes a complete health history and a
full physical examination; it describes the current and past
health state and forms a baseline against which all future
changes can be measured. An emergency database is a rapid
collection of data often obtained concurrently with lifesaving
measures. A focused database is for a limited or short-term
problem; this database concerns mainly one problem, one cue
complex, or one body system. Medical diagnoses are used to
evaluate the cause or etiology of the disease.
A nurse precepting a student nurse asks, "What's the most
important step in the critical-thinking process?"
a. Clustering subjective and objective data
b. Analyzing health data
c. Using evidence-based assessment techniques
d. Prioritizing health concerns Correct Answers c. Using
evidence-based assessment techniques
Evidence-based techniques are supported by research showing
effectiveness of the technique that provides the safest and most
current techniques to promote the health of patients. Clustering
subjective and objective data is a step in the critical-thinking
process, but is not the most important step. Analyzing health
data is a step in the critical-thinking process, but is not the most
,important step. Prioritizing health concerns is a step in the
critical-thinking process, but is not the most important step.
A patient admitted to the hospital with asthma has the following
problems identified based on an admission health history and
physical assessment. Which problem is a first-level priority?
a. Ineffective self-health management
b. Impaired gas exchange
c. Readiness for enhanced spiritual well-being
d. Risk for infection Correct Answers b. Impaired gas
exchange
First-level priority problems are problems that are emergent,
life-threatening, and immediate. Impaired gas exchange is an
emergent and immediate problem. Third-level priority problems
are problems that are important to the patient's health but can be
addressed after more urgent health problems are addressed.
Ineffective self-health management is an example of a third-
level priority. Second-level priority problems are problems that
are next in urgency; these problems require prompt intervention
to forestall further deterioration. Risk for infection is an example
of a second-level priority. Third-level priority problems are
problems that are important to the patient's health but can be
addressed after more urgent health problems are addressed.
Wellness diagnoses are third-level priority problems.
A patient seeks care for "debilitating headaches that cause
excessive absences at work." On further exploration, the nurse
asks, "What makes the headaches worse?" With this question,
the nurse is seeking information about
, a. the patient's perception of pain.
b. the nature or character of the headache.
c. relieving factors.
d. aggravating factors. Correct Answers d. aggravating factors.
Aggravating factors are determined by asking the patient what
makes the pain worse. To determine the patient's perception of
pain, the nurse would determine the meaning of the symptom by
asking how it affects daily activities and what the patient thinks
the pain means. The nature or character calls for specific
descriptive terms to describe the pain. Relieving factors are
determined by asking the patient what relieves the pain, what is
the effect of any treatment, what the patient has tried, and what
seems to help.
A woman seeks medical attention for a cut made by a knife
during a physical assault. The health care provider would
document the cut as an
a. incision.
b. ecchymosis.
c. avulsion.
d. abrasion. Correct Answers a. incision.
An incision is a cut or wound made by a sharp instrument.
Ecchymosis is a hemorrhagic spot or blotch in the skin or
mucous membrane that forms a non-elevated, rounded or
regular, blue or purplish patch. An avulsion is the tearing away
of a structure or part. An abrasion is a wound caused by rubbing
the skin or mucous membrane.
