Rasmussen Health Assessment Exam 1, questions and answers

Rasmussen Health Assessment Exam 1, questions and answers After completing an initial assessment of a patient, the nurse has charted that his respiration's are eupneic and his pulse is 58 beats per minute. These types of data would be Objective A patient tells the nurse that he is very nervous, is nauseated, and "feels hot" These types of data would be Subjective The patients record, laboratory studies, objective data, and subjective data combine to form the Database When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to Validate the data by asking a coworker to listen to the breath sounds. The nurse is reviewing information about EBP. Which statement best reflects EBP? EBP emphasizes the use of best evidence with the clinician's experience. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem? Individual with shortness of breath and respiratory distress When considering priority setting of problems, the nurse keeps in mind that second level priority include which of these aspect? Abnormal lab values The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the _______________ diagnosis. Nursing The nursing process is a sequential method of problem solving the nurses use and includes which steps? Assessment, diagnosis, outcome identification, planning, implementation, and evaluation A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems. Breathing, pain, sleep. What step of the nursing process includes data collection by health history, physical exam, and interview Assessment When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these Holistic health views the mind, body, and spirit as interdependent The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes 2-5 cm scar on the right lower forearm A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting A complete health data base because of the nurses primary responsibility for monitoring the patients health Which situation is most appropriate during which the nurse performs a focused of problem- centered history Patient in an outpatient clinic has cold and flu symptoms A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medication 2 months ago. The nurse should Collect a follow up data vase and the check her blood pressure A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection Simultaneously ask history questions while performing exam and initiating life saving measures a 42 year old patient of Asian descent is being seen at the clinic for an initial exam. The nurse knows that including cultural information in his health assessment is important to Provide culturally sensitive and appropriate care the nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next step Evaluate the individuals condition, and compare actual outcomes with expected outcomes Each culture has its own healers who usually cost less than traditional biomedical providers when evaluating health history, the nurse determines that the patient subscribes to the hot/cold theory of health the humors are balanced on the basis of median age asian population tends to be younger spirituality is defined as a personal effort to find meaning and purpose in life which statement regards to language barriers and health care there is a law that addresses barriers in healthcare what is yin/yang theory when all aspects of the person are in perfect balance which theory has been expanded in an attempt to study the degree to which persons heritage lifestyle reflects heritage heritage consistency which symptom is greatly influenced by persons cultural heritage pain when considering cultural competence, the nurse must develop his/her own heritage the nurse is reviewing the development of culture. which statement is correct regarding the development of ones culture learned through language acquisition and socialization during a class on the aspects of culture, the nurse shares that culture has four basic characteristics. culture adapts to specific environmental factors and available natural resources the nurse is reviewing the development of culture. which statement is correct regarding the development of ones culture. culture is learned through language acquisition and socialization 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 culture adapts to specific environmental factor and available natural resources during a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating "the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society" reflects which term culture when discussing the use of the term subculture the nurse recognizes that it is best described as identifying faily large groups of people with shared characteristics that are not common to all members of a culture when reviewing the demographics of ethic groups in the united states, the ensure recalls that the largest and fastest growing population is hispanic during an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. which action by the nurse is appropriate ask the patient about the item and its significance after a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement "ethnicity pertains to a social group within the social system that claims shared values and traditions a woman who has lived in the US for a year after moving from Europe has learned to speak English and is almost finished with college. she now dresses like her peers and says her family in Europe would hardly recognize her. this nurse recognizes that this situation illustrates which concept assimilation in the majority culture of america, coughing, sweating, and diarrhea are symptoms of an illness. for some individuals of Mexican american origin, however, these symptoms are a normal part of living. the nurse recognizes that this difference is true, probably because Mexican Americans consider these symptoms part of normal living, not symptoms of ill health as Asian american woman is experiencing diarrhea, which is believed to be "cold" or "yin." the nurse expects that the woman is likely to try to treat it with foods that are "hot" or "yang" many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. which statement most accurately reflects "health" in an Asian with this belief all aspects of the person are in perfect balance illness is considered part of lifes rhythmic course and is an outward sign of disharmony withing. this statement most accurately reflects the views about illness from which theory naturalistic if an american Indian woman has come to the clinic to seek help with regulating her diabetes, the the nurse can expect that she may also be seeking the assistance of a shaman or medicine man an older Mexican american woman with tradition beliefs has been admitted to an inpatient care unit. a culturally sensitivities nurse would further assess the patients cultural beliefs and off the patient assistance in contacting a curandero or priest if she desires symptoms, such as pain, are often influenced by a persons cultural heritage. which of the following is a true statement regarding pain nurses need to recognize that many cultures practice silent suffering as a response to pain the nurse is reviewing concepts of cultural aspects of pain. which statement is true regarding pain just as patients very in their perceptions of pain, so will they vary in their expressions of pain the nurse is reviewing the hot/cold theory of health and illness. which statement best describes the basic tenets of this theory the treatment of disease consists of adding or subtracting cold, heal, dryness, or wetness to restore balance in the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. which of these patient conditions is most consistent with a cold condition older man with gastrointestinal discomfort when providing culturally compentent care, nurses must incorporate cultural assessments into their health assessments. which statement is most appropriate to use when initiating as assessment of cultural beliefs with an older american indian patient what cultural or siritual beliefs are important to you the nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of subcultures the nurse is reviewing concepts related to ones heritage and beliefs. the belieg in divine or superhuman powers to be obeyed and worshipped as the creators and rulers of the universe is known as religion when planning a cultural assessment, the nurse should inculde which component health related beliefs when preparing the physical setting for an interview, the intervivewer should conduct interview at eye level and at a distance of 4-5 feet the use of euphemisms to avoid reality or hide feelings is known as avoidance language viewing the world from another persons inner frame of reference is called empathy The nurses conducting an interview with a woman who has recently learned that she is pregnant and who a has come to the clinic today to begin prenatal care the woman States that she and her husband are excited about the pregnancy but have a few questions she looked nervously at her hands during the interview and sighs loudly considering the concept of communication which statement does a nurse note to be most accurate the woman is Exhibiting verbal and nonverbal behaviors that do not match Receiving is a part of the communication process. Which receiver is most likely to misinterpret it a message sent by a health care professional? Man whose wife has just been diagnosed with lung cancer The nearest makes an adjustment in the physical environment to promote the success of an interview Reduces noise by turning off television and radio shows Reduces noise by turning off television and radio showsIn an interview the nurse may find it's necessary to take notes to aid his or her memory later. Which statement is true regarding note taking? Note taking may impede the nurse's observation of the patient's nonverbal behaviors That nursed ask I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here the question is found at the phase ______________ of the interview process Opening or introduction A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? Mrs. H my name is mrs C ill need to ask a few questions about what happened During an interview the nurse States you mentioned having shortness of breath tell me more about that which verbal skills is used with this statement Open ended question A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalization is missing. At this point, which statement by the nurse would be most appropriate to gather this information Mr. y I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain? When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would the nurse's best response to this behavior? Be silent, and allow him to continue when he is ready. A woman is discussing the problem she is having with her two-year-old son. She says, he won't go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurse's best verbal response would be Fits? Tell me what you mean by this A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through an interview, one of the standard questions has to do with alcohol, to vacco, and drug use. When the nurse asked him how tobacco use, he States I quit smoking after my wife died 7 years ago. However the nurse notices and open pack is cigarets in his shirtPocket. Using confrontation the nurse could say Mister k you haveSaid that you don't smoke, but I see you have a open pack of cigarettes in your pocket The nurse has used interpretation regarding a patient's statement or actions. After using this Technique, it would be best for the nurse to Allow time for the patient to confirm or correct inference During an interview a woman says I have decided that I can no longer allow my children to live with their father's violentence but I just can't seem to leave him using interpretation the nurse's best response would be It sounds as if you might be afraid of how your husband will respond During a visit to the clinic, a patient States, the doctor just told me he thought I ought to stop smoking. He does not understand how hard I've tried. I just don't know the best way to do it. What should I do the nurses most appropriate response in this case would be Would you like some information about the different ways a person can quit smoking