Exam 1: NR226/ NR 226 Fundamentals Patient Care Exam Practice| Questions and Verified Answers (Latest 2023/ 2024 Update)- Chamberlain
QUESTION
Which
... [Show More] of the following are examples of data validation? (Select all that apply.)
A. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record.
B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity.
C. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content.
D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement.
E. The nurse asks the patient to describe a symptom by saying, "Go on."
Answer:
A & D
-Validation involves comparing data with another source. By asking the patient about pain and then having it rated the nurse collects two assessment findings. The nurse asking an open-ended question about the patient's understanding of the booklet is not data validation. Telling the patient to "go on" is back channeling.
QUESTION
A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing?
A. So you've had an upset stomach and began vomiting—correct?
B. Have you taken anything for your stomach?
C. Is anything else bothering you?
D. Have you taken any medication for your vomiting?
Answer:
C. Is anything else bothering you?
-A probing question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements. Confirming an upset stomach and vomiting is an example of summarizing findings. The questions about medications taken are examples of closed-ended questions that control the patient's response and do not ensure a full objective view from the patient.
QUESTION
The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following?
A. An objective finding
B. A clinical inference
C. A validation
D. A concomitant symptom
Answer:
D. A concomitant symptom
-A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.
QUESTION
During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.)
A. Family report
B. Chest x-ray film
C. Physical examination with auscultation of the lungs
D. Medical record summary of x-ray film findings
Answer:
C & D
-The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem.
QUESTION
A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.)
A. A problem-focused approach
B. A structured comprehensive approach
C. Using multiple visits to gather a complete database
D. Focusing on the functional health pattern of role-relationship
Answer:
A & C
-The nurse should use a focused approach initially to determine the patient's respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient's age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient's role-relationship health pattern because of his wife's death. But it is not appropriate at this time.
QUESTION
A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.)
A. Maintain a neutral facial expression
B. Lean forward when interacting with the patient
C. Acknowledge the patient's answers through head nodding
D. Limit direct eye contact
Answer:
B & C
-Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse's responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse's interest in what the patient has to say.
QUESTION
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
A. Anxiety related to fear of dying
B. Fatigue related to chronic emphysema
C. Need for mouth care related to inflamed mucosa
D. Risk for infection
Answer:
A & D
-The diagnosis "Anxiety related to fear of dying" is stated correctly, with the related factor being the patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing diagnosis.
QUESTION
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in:
A. Data collection.
B. Data clustering.
C. Data interpretation.
D. Making a diagnostic statement.
Answer:
C. Data interpretation
-In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.
QUESTION
The nursing diagnosis readiness for enhanced communication is an example of a(n):
A. Risk nursing diagnosis.
B. Actual nursing diagnosis.
C. Health promotion nursing diagnosis
D. Wellness nursing diagnosis.
Answer:
C. Health promotion nursing diagnosis
-A patient's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient's motivation and desire to strengthen his health. [Show Less]