Solutions
/. Match the terms below with the correct definitions
1. assessment
2. nursing diagnosis
3. planning
4. implementation
5. evaluation
a. clinical judgement about individual, family, or community responses to actual or
potential health problems and life processes
b. assessing whether outcome criteria have been met and revising the plan of care if
necessary
c. collection of subjective and objective data
d. developing a plan of nursing care and outcome criteria
e. carrying out the plan - Answer-1. c
2. a
3. d
4. e.
5. b
/.Which on the of the following groups is very time conscious and maintains eye contact
while speaking to another person?
a. Asian
b. African-American
c. Hispanic
d. Euro-American - Answer-D
/.What is the policy called that requires using protective measures to minimize the
exposure to potentially infectious body fluids?
a. hand washing
b. body substance isolation
c. standard precautions
d. common sense - Answer-C
,/.A simplified, generally inflexible conception of the members of a group or subgroup is
the definition of which of the following terms?
a. ethnocentrism
b. stereotype
c. cultural sensitivity
d. ethnicity - Answer-B
/.George is a 50 year old male that has never sought preventative care prior to today.
He arrives at a primary care clinic for the first time. The Registered Nurse (RN) will
perform what type of assessment upon meeting George?
a. initial/comprehensive
b. ongoing/partial
c. focused/problem
d. emergency - Answer-A
/.Physical assessment provides which type of data?
a. Subjective
b. Objective
c. Symptoms
d. Current medical history - Answer-B
/.The nurse is interviewing for the first time, a Hispanic patient with limited English skills.
The nurse observes that the patient is reluctant to reveal personal information and that
he believes in a hot-cold syndrome of disease causation. What should the nurse do in
this situation?
a. Request a family member interpret for the patient
b. Indicate acceptance of the patient's cultural differences
c. Use slang terms to identify certain body parts
d. Remain in a standing position during the interview - Answer-B
/.Because the nurse realizes that spirituality varies, how will the information gained
during a spirituality assessment assist the nurse?
a. By individualizing interventions to meet specific needs
b. In diagnosing the patient with spiritual distress
c. In teaching the patient strict adherence to rituals and practices to improve outcomes
d. By providing an overview of widely held beliefs from the major religions - Answer-A
/.Asking a colleague to recheck a blood pressure to see if he/she gets a similar reading
as you, is an example of which of the following?
a. Reflection
,b. Validation
c. Interpretation
d. Documentation - Answer-B
/.Match the following signs and symptoms to the appropriate type of data/
Objective/Subjective
1. warm and dry skin
2. respiration's of 16 breaths per minute
3. pain rated 9 out of 10
4. a complaint of feeling bloated
5. scattered freckles across face of cheeks - Answer-1. objective
2. objective
3. subjective
4. subjective
5. objective
/.What is the term (when defined broadly) that describes a body of shared traits, art, or
ideas?
a. Culture
b. Customs
c. Rituals
d. Values - Answer-A
/.Which assessment takes priority in an emergency assessment of a patient?
a. Pulse
b. Blood pressure
c. Airway/breathing
d. Skin color - Answer-C
/.Match the terms below with the correct descriptions
1. normal diastolic BP range
2. diastolic blood pressure
3. normal oral temp
4. normal systolic BP range
5. normal resp rate
6. normal pulse
7. systolic blood pressure
8. pulse pressure
9. overall impression
10. 5th vital sign
a. less than 120 mmHg
, b. highest pressure exerted on the artery walls
c. skin color, hygiene, posture, gait, physical build, and development
d. difference between systolic and diastolic pressure
e. 36.6 degrees C to 37 degrees C (96.0 degrees F to 99.9 degrees F)
f. 12 to 20 per min
g. 60 to 100 beats per min
h. pain
i. lowest pressure exerted on the artery walls
j. less than 80 mmHg - Answer-1. j
2. i
3. e
4. a
5. f
6. g
7. b
8. d
9. c
10. h
/.While caring for an 80 year-old client in his home, the nurse determines that the
client's temperature is 96.5 degrees F. The nurse determines that the client is most
likely exhibiting
a. normal changes that occur with the aging process
b. hypothermia that occurs before an infectious process
c. a metabolic disorder resulting in circulatory changes
d. an immune disorder resulting in low platelet count - Answer-A
/.The nurse is preparing to assess the respirations of an alert adult client. The nurse
should
a. explain to the client that he or she will be counting the client's respirations
b. unobtrusively observe for the equal bilateral chest expansion while continuing to
palpate the radial pulse site
c. count fo 15 seconds and multiply the number by 4 to obtain the rate
d. ask the client to lie in a supine position, which makes counting the respirations easier
- Answer-B
/.How is Acute pain different from Chronic pain?
a. Acute pain is often associated with tissue damage and lasts less than 6 months in
duration
b. Acute pain usually does not need to be treated but chronic pain is referred for
treatment