Final Exam: NR222 / NR 222 (Latest 2023/ 2024 Update) Health & Wellness Exam Review| Grade A| Questions and Verified Answers -Chamberlain
QUESTION
*
... [Show More] Which of the following examples are steps of nursing assessment?
Answer:
Collection of information from patient's family members.
Recognition that further observations are needed to clarify information.
Comparison of data with another source to determine data accuracy.
Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step.
QUESTION
* A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem?
Answer:
The skin around the wound is tender to touch.
Patient has drainage from surgical wound.
Body temperature is 38.3° C (101° F).
Tender skin around the wound, drainage from the surgical wound, and a temperature of 38.3° C (101° F) indicate a wound infection. Fluid intake of 800 mL over 8 hours and a heart rate of 78 beats/min and regular are normal assessment findings. A patient's expressed concern about returning to work is his or her subjective response about a separate issue and is insufficient to form a pattern.
QUESTION
* A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient?
Answer:
The nurse asks the patient to rate his pain on a scale of 0 to 10.
The nurse assesses the patient's lower-limb strength.
Validation of assessment data is the comparison of data with another source to determine its accuracy. The nurse compares data reported by the previous nurse with data collected directly with the patient, including assessing pain on the rating scale and assessing the patient's lower limb strength. Asking the patient what caused his fall and about past back pain and experience with pain medications would offer the nurse new information about the patient.
QUESTION
A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
Answer:
Patient's level of function.
Observing a patient perform activities physical, socially, psychologically, and developmentally assesses his or her level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self-care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient's values.
QUESTION
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?
Answer:
Working phase.
The gathering of information is the working phase of a patient-centered interview.
QUESTION
The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult?
Answer:
Listen attentively to the patient's story.
Use gestures that reinforce your questions or comments.
Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.
Approaches for collecting an older-adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patientdirected eye gaze. Leaning forward, not backward, shows interest in what the patient has to say.
QUESTION
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
Answer:
Clinical inference.
An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal process of thinking back about a situation.
QUESTION
Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?
Answer:
Open-ended.
The best interview question for initially determining why a patient is seeking health care is by asking an open-ended question that allows the patient to tell his or her story. This is also a more patient-centered approach. Probing questions are asked after data are gathered to seek more in-depth information. Problem-oriented and confirmation are not types of interview questions.
QUESTION
When a nurse conducts an assessment, data about a patient often comes from which of the following sources?
Answer:
An observation of how a patient turns and moves in bed.
The care recommendations of a physical therapist.
The results of a diagnostic x-ray film.
There are many sources of data for an assessment, including the patient through interview, observations, and physical examination; family members or significant others, health care team members such as a physical therapist, the medical record (which includes x-ray film results, and the scientific and medical literature.
QUESTION
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?
Answer:
Health perception-health management pattern.
The nurse's assessment covers the health perception- health management pattern, which is a patient's self-report of how he or she manages his or her health and his or her knowledge of preventive health practices. The coping-stress tolerance pattern includes questions focused on how a patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs, and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient's language adequacy, memory, and decision-making ability. [Show Less]