Medical Surgical Nursing Preparation For Practice 2nd Ed By Osborn – Test Bank

Medical Surgical Nursing Preparation For Practice 2nd Ed By Osborn – Test Bank Osborn, Medical-Surgical Nursing, 2e Question 1 Type: MCSA While conducting a health assessment, the nurse documents a patient’s response under the heading “chief complaint.” Which part of the assessment is the nurse conducting? 1. History of present illness 2. Family history 3. Psychosocial history 4. Past medical history Correct Answer: 1 Rationale 1: The history of the present illness includes information about what brought the patient to the health care provider. The reason is usually written verbatim in the health record and often becomes the chief complaint. Rationale 2: The patient’s chief complaint is not part of the family history. Rationale 3: The patient’s chief complaint is not part of the psychosocial history. Rationale 4: The patient’s chief complaint is not part of the past medical history. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-1 Question 2 Type: MCSA A patient comes to the emergency department and states, “I am having chest pain and I feel short of breath.” How is the data the patient has just given the nurse classified? 1. Nonspecific 2. Objective 3. Factual 4. Subjective Correct Answer: 4 Rationale 1: Nonspecific is not a term used to describe types of assessment data. Rationale 2: Objective data is information collected when the nurse uses the senses: observation, palpation, auscultation, percussion, and smell. Rationale 3: Factual is not a term used to describe types of assessment data. Rationale 4: Subjective data is information the patient provides to the nurse. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3 Question 3 Type: MCSA The nurse has completed the collection and analysis of data from a patient assessment. What is the nurse’s next action? 1. Evaluate outcomes from care. 2. Plan care. 3. Determine patient care goals. 4. Formulate nursing diagnoses. Correct Answer: 4 Rationale 1: Evaluation occurs after care is implemented. Rationale 2: Planning occurs later in the nursing process. Rationale 3: Determining patient goals is a later step of the nursing process. Rationale 4: Once data is collected, it is used to formulate nursing diagnoses, which is the next step of the nursing process. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-2 Question 4 Type: MCSA The nurse asks the patient, “What brings you to the hospital today?” What is the nurse’s rationale for using this type of question? 1. It acknowledges agreement between the patient and the nurse. 2. It elicits specific information. 3. It is useful for introducing a subject in general terms. 4. It helps to clarify information. Correct Answer: 3 Rationale 1: The question does not acknowledge agreement between the patient and the nurse. The nurse’s summary at the end of the interview acknowledges agreement. Rationale 2: Direct questions are used to elicit specific information. Rationale 3: The question is an open-ended question and asks for narrative information by stating the topic in general terms. It is used to introduce a topic. Rationale 4: The question does not help to clarify information. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3 Question 5 Type: MCSA While conducting a health history, the nurse nods her head as the patient is talking. What is the nurse’s primary rationale for this action? 1. It conveys acknowledgment of the patient’s feelings. 2. It helps to reduce the patient’s anxiety level. 3. It encourages the patient to continue talking. 4. It allows the nurse time to observe the patient’s nonverbal cues. Correct Answer: 3 Rationale 1: Empathy is used to acknowledge the patient’s feelings. Rationale 2: Explanation will reduce the patient’s anxiety level. Rationale 3: Nodding the head encourages the patient to tell the nurse more and is considered facilitation. Rationale 4: The use of silence will allow the nurse time to observe the patient’s nonverbal cues. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3 Question 6 Type: MCSA A patient tells the nurse that he has a history of back pain that is controlled with yoga and herbal supplements. How would the nurse document this information? 1. The patient does not believe in Western medicine. 2. The patient has strong spiritual beliefs. 3. The patient uses some alternative forms of medicine to treat illness. 4. The patient uses stress reduction techniques to control back pain. Correct Answer: 3 Rationale 1: Western medicine is the type of health care traditionally provided in the United States and includes diagnostic testing, treatments, and medications. There is no indication that the patient does not believe in Western medicine. Rationale 2: The strength of the patient’s spiritual beliefs cannot be assessed by this information alone. Rationale 3: The use of herbal supplements to relieve back pain is a form of complementary or alternative medicine. The nurse must assess this practice, as some “natural cures” are ineffective and some can interfere with prescribed medications. Rationale 4: There is not enough information to make this statement. The patient may use yoga as a strengthening exercise for back muscles. The herbs may not be taken for stress reduction. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 06-01 Question 7 Type: MCSA The nurse introduces herself and shakes the patient’s hand, then sits so as to maintain eye contact during the health interview. What do the nurse’s actions demonstrate? 1. Facilitation 2. Negative nonverbal messages 3. Positive nonverbal messages 4. Empathy Correct Answer: 3 Rationale 1: Facilitation would occur if the nurse nodded the head to encourage the patient to continue talking. Rationale 2: Negative nonverbal messages include tense posture, yawning, and avoiding eye contact. The nurse’s actions are not negative. Rationale 3: Positive nonverbal messages enhance the relationship with the patient and include eye contact and equal-status seating. Rationale 4: Empathy is acknowledging a patient’s feelings with a statement of understanding. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3 Question 8 Type: MCSA During the health history, a patient tells the nurse that she is in an abusive relationship and is fearful of getting hurt if her husband finds out that she told the nurse. Which response by the nurse is most appropriate for this patient? 1. “Don’t worry. They only strike back when they are angry.” 2. “Are you saying that you are in danger?” 3. “I would get an attorney if I were you.” 4. “Remember, what goes around comes around.” Correct Answer: 2 Rationale 1: This answer does not promote the patient’s health. Rationale 2: The nurse needs to clarify what the patient is explaining, and the best response would be to clarify if the patient is saying she is in danger. Rationale 3: The nurse should not offer legal advice to the patient. Rationale 4: This statement dismisses the patient’s concern for her safety and does not promote her health. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-3 Question 9 Type: MCSA During an assessment, the patient describes shoulder pain. The nurse responds, “So, you have this shoulder pain when you eat fried foods or ice cream, is that correct?” The nurse is using which interview technique? 1. Facilitation 2. Empathy 3. Interpretation 4. Summary Correct Answer: 3 Rationale 1: Facilitation is a technique that would encourage the patient to continue talking. Rationale 2: Empathy acknowledges the patient’s feelings with a statement of understanding to help the patient feel accepted. Rationale 3: Interpretation links events or implies a cause, which is what the nurse is doing when responding to this patient. Rationale 4: Summary occurs at the end of the interview, when the nurse summarizes the perception of the patient’s health problem from the information gained during the interview. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3 Question 10 Type: MCSA The nurse notices a patient has a strong, foul body odor. The patient tells the nurse he has trouble getting in and out of the bathtub. Which areas of the physical assessment does this information address? 1. Behavior and pain 2. Nutritional assessment, mental status, and behavior 3. Physical appearance, height, and weight 4. Functional assessment, physical appearance, and mobility Correct Answer: 4 Rationale 1: The patient did not say that his inability to use the bathtub was associated with pain, and the nurse should be careful not to make this assumption. Rationale 2: An inability to use the bathtub does not speak specifically to nutrition, mental status, or behavior. Rationale 3: The inability to use the bathtub does affect physical appearance. The patient did not mention that the tub was too small or that his weight made using it difficult, so these issues cannot currently be considered a factor. The nurse must be careful not to make assumptions without data. Rationale 4: The patient states difficulty with using a bathtub, which provides information relevant to functional assessment, physical appearance, and mobility. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-4 Question 11 Type: MCSA Prior to palpating the abdomen of a patient with several skin lesions, the nurse puts on a pair of gloves. The patient asks, “What are the gloves for?” Which is the best response the nurse can give the patient? 1. “Gloves are considered a standard precaution to provide protection to the health care provider during an exam.” 2. “I don’t want to catch anything from you.” 3. “I prefer to wear gloves when touching people.” 4. “The gloves help me to grip my equipment better.” Correct Answer: 1 Rationale 1: The nurse needs to use standard precautions throughout the entire physical examination and should explain this to the patient. Gloves are particularly important when skin lesions are present. Rationale 2: The nurse should not make the patient feel “dirty” or “bad” when answering this question. Rationale 3: This should not be the reason the nurse is wearing gloves and is not an appropriate answer. Rationale 4: This statement is not accurate. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-4 Question 12 Type: MCMA While performing percussion in a physical examination, the nurse elicits dullness. Which structure is the nurse likely percussing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Intestines 2. Lungs 3. Pelvic bone 4. Liver 5. Kidney Correct Answer: 4,5 Rationale 1: Tympany is the percussion sound heard over air-filled intestines. Rationale 2: Resonance is the percussion sound heard over normal lungs. Rationale 3: Flatness is the percussion sound heard over muscle and bone. Rationale 4: Dullness is the percussion sound heard over large, solid organs such as the liver. Rationale 5: Dullness is the percussion sound heard over large, solid organs such as the kidney. Global Rationale: Cognitive Level: Applying