Homework Lance
1. The nurse clarifies that the difference between a health screening and health assessment is that a health screening:
a.
identifies persons with unmet health needs who may need a referral.
b.
assesses local health needs for the Public Health Department.
c.
collects data that will be used for research.
d.
provides appropriate treatment for identified health needs.
ANS: A
Screenings are to identify unmet health needs and to refer identified persons to an appropriate resource for assessment and treatment.
DIF: Cognitive Level: Comprehension REF: 151 OBJ: 1
TOP: Screening vs. Assessment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. The nurse charts that the “Patient stated abdominal pain is still at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8°.” The objective information recorded is the:
a.
pain measurement.
b.
presence of nausea.
c.
sense of cold.
d.
oral temperature.
ANS: D
The objective concrete measurement of the temperature is the only objective data in the nurse’s record.
DIF: Cognitive Level: Application REF: 151 OBJ: 2
TOP: Objective Data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. The nurse reminds the 55-year-old woman that the American Cancer Society (ACS) recommendation for persons older than 50 years is to have an annual:
a.
fecal occult blood test.
b.
sigmoidoscopy.
c.
Pap smear.
d.
pelvic examination.
ANS: A
The ACS recommends an annual fecal occult blood test for persons older than 50. Sigmoidoscopy is recommended every 3 to 5 years. Pap smears and pelvic examinations are recommended every 2 to 3 years.
DIF: Cognitive Level: Comprehension REF: 152, Table 8-1
OBJ: 3 TOP: American Cancer Society Recommendations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. The nurse is aware that the most common health threat for the older adult, regardless of ethnicity, is:
a.
hypertension.
b.
cancer.
c.
diabetes.
d.
glaucoma.
ANS: C
Diabetes is the most common health threat for the older adult, regardless of ethnicity.
DIF: Cognitive Level: Comprehension REF: 158 OBJ: 3
TOP: Diabetes KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. The statement that would put the older woman most at ease during the lengthy health interview would be:
a.
“This interview will take about an hour.”
b.
“Please have a seat over there across from the desk.”
c.
“There are 75 questions we need to get answered in the next hour.”
d.
“The bathroom is behind that green door. We’ll be taking a break in about 30 minutes.”
ANS: D
The “permission” to go to the bathroom and knowledge of its location will set the patient at ease. It is helpful to provide information about the probable time limits of the interview.
DIF: Cognitive Level: Application REF: 153 OBJ: 4
TOP: Physical Setting for Health Interview
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. To establish rapport, the nurse should initiate the health interview by saying:
a.
“Hello, Mrs. Smith. My name is Alice. We’ll start with a few questions before the physical exam.”
b.
“Welcome, Sara. I’m Alice. Let’s get down to some questions about your health.”
c.
“I’m Alice Jones. I’m here to do an interview about your health.”
d.
“Hey, Mrs. Smith! Are you ready for some questions about your health?”
ANS: A
Addressing the patient formally and identifying yourself, as well as informing the patient of the expectation of the interview, is an appropriate approach to the older adult.
DIF: Cognitive Level: Application REF: 153 OBJ: 4
TOP: Establishing Rapport KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
7. The 94-year-old woman has come to the health assessment interview with her 70-year-old daughter, who answers all the interview questions for her mother. The nurse’s best approach to this situation would be to:
a.
say, “I’m speaking to your mother. Please let her answer for herself.”
b.
continue to interact with the daughter to facilitate completion of the interview.
c.
look directly at the patient and say, “Mrs. Smith, now I’d like to hear from you about your health.”
d.
document that all answers to the interview came from a third party.
ANS: C
Directly addressing the older adult cues the patient and family member that the responses are expected from the patient.
DIF: Cognitive Level: Analysis REF: 153 OBJ: 4
TOP: Establishing Rapport KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. The most effective method of building rapport is to open the health interview with:
a.
focusing on the problems that the patient sees as important.
b.
explaining the importance of health maintenance.
c.
informing the patient of the number of questions that will be asked.
d.
reassuring the patient that the interview is private.
ANS: A
Focusing on the patient’s concerns gives the patient the perception that the nurse is concerned about him or her as a person.
DIF: Cognitive Level: Application REF: 153 OBJ: 4
TOP: Establishing Rapport KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
9. When interviewing a 90-year-old Chinese woman who is accompanied by her daughter, the interviewer should:
a.
use direct, short questions.
b.
address all the questions to the daughter.
c.
use pictures of body systems rather than anatomical terms.
d.
use social conversation and indirect questions.
ANS: D
Persons with an Asian background consider direct questions inappropriate and they are more comfortable with indirect questioning in a social context. Rather than saying, “How many bowel movements do you have a day?” it would be better to ask, “How would you describe your digestion?”
DIF: Cognitive Level: Analysis REF: 153, Cultural Considerations
OBJ: 4 TOP: Cultural Considerations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
10. The nurse appropriately uses a variety of communication techniques during the health interview, which include:
a.
using medical terminology.
b.
keeping questions simple.
c.
helping patients by finishing their sentences.
d.
allowing patients to ramble as they respond.
ANS: B
Keeping questions simple and asking the question in a clear voice help patients process answers. Finishing their sentences and allowing extensive rambling are not helpful for useful interviewing.
DIF: Cognitive Level: Application REF: 153-154 OBJ: 4
TOP: Structuring the Interview KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. An 85-year-old man accompanied by his son is unable to recall the medications that he is presently taking. The nurse should:
a.
ask the question again.
b.
rephrase the question.
c.
ask the son for the information.
d.
leave that part of the health history blank.
ANS: C
When patients are unsure of answers, it is best to move on and ask the family for objective information.
DIF: Cognitive Level: Application REF: 154 OBJ: 4
TOP: Health History KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. Because the nurse is aware that the 86-year-old woman has age-related loss of subcutaneous fat and a lowered metabolism rate, the nurse will take special precautions to:
a.
weigh the patient carefully without clothing.
b.
prevent the patient from becoming chilled during the examination.
c.
give fluids before the examination.
d.
elevate the patient’s head while he or she is lying in a supine position.
ANS: B
Because of loss of subcutaneous fat and lower metabolism, the older adult has altered thermoregulation. Care should be taken to prevent chilling during the physical examination.
DIF: Cognitive Level: Application REF: 155 OBJ: 6
TOP: Prevention of Chilling KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. The nurse performing an assessment of a 90-year-old man suspected of having an upper respiratory infection would expect to find:
a.
temperature elevation over 100° F.
b.
elevated white blood count.
c.
history of recent periods of confusion.
d.
record of increased fluid intake.
ANS: C
The older adult does not exhibit a marked increase in temperature or in the white blood count as a response to infection. History of confusion and a decrease in appetite and fluid intake are cardinal signs of infection in the older adult.
DIF: Cognitive Level: Application REF: 155, Table 8-3
OBJ: 5 TOP: Infection Assessment in the Older Adult
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. During the health interview, when the older adult offers vague physical gastrointestinal complaints, complains of inability to fall asleep, has frequent periods of wakefulness during the night, and has a decrease in appetite, the nurse would be cued to inquire about:
a.
feelings of depression.
b.
time of last bowel movement.
c.
environmental stimuli that disturb sleep.
d.
frequency and size of meals.
ANS: A
Vague physical complaints, sleep disturbances, and changes in appetite and food intake are signals of possible depression.
DIF: Cognitive Level: Analysis REF: 155, Table 8-3
OBJ: 4 TOP: Symptoms of Depression
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. The most effective method to take an older adult’s temperature is to use a(n):
a.
electronic thermometer, because it only takes a few seconds to assess temperature.
b.
oral thermometer, because the presence of dry mucous membranes gives a more valid temperature.
c.
axillary thermometer, because its position is nearer the heart.
d.
rectal thermometer, because it is the best indicator of the body core temperature.
ANS: A
The electronic thermometer is the best device because it is accurate and quick.
DIF: Cognitive Level: Comprehension REF: 156 OBJ: 8
TOP: Temperature Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. The nurse is aware that the difference between the apical pulse and radial pulse is referred to as the pulse:
a.
pressure.
b.
deficit.
c.
ratio.
d.
quality.
ANS: B
The difference between the apical and radial pulse is referred to as the pulse deficit. This is a pertinent piece of information because it may indicate peripheral circulatory impairment.
DIF: Cognitive Level: Knowledge REF: 157 OBJ: 8
TOP: Pulse Deficit KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17. The nurse records the assessment of crackles when the nurse auscultates:
a.
high-pitched sounds in the lung bases on inspiration.
b.
continuous low-pitched snoring sounds over major bronchi.
c.
squeaky musical sounds on expiration.
d.
coarse grating sounds on inspiration and expiration.
ANS: A
Crackles are adventitious breath sounds heard on inspiration that sound like cracking paper. Frequently, these sounds can be cleared by coughing.
DIF: Cognitive Level: Application REF: 160, Box 8-2
OBJ: 7 TOP: Adventitious Breath Sounds
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. The nurse assessing the apical pulse would place the head of the stethoscope at the:
a.
third intercostal space at proximal edge of the clavicle.
b.
fourth intercostal space at the edge of the sternum.
c.
fifth intercostal space at the middle of the clavicle.
d.
sixth intercostal space above the diaphragm.
ANS: C
The correct placement of the stethoscope for the assessment of the apical pulse is at the fifth intercostal space at the midclavicular line. The pulse should be counted for a full minute.
DIF: Cognitive Level: Application REF: 157 OBJ: 8
TOP: Apical Pulse KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
19. The nurse assessing a patient for orthostatic hypotension has a reading of a seated blood pressure of 135/86. The blood pressure that would be indicative of orthostatic hypotension would be a standing blood pressure of:
a.
145/85.
b.
134/76.
c.
130/72.
d.
126/62.
ANS: D
Orthostatic hypotension is suspected when the systolic reading is 20 mm Hg lower than the sitting blood pressure. Dizziness with a diastolic pressure less than 100 mm Hg should also be reported.
DIF: Cognitive Level: Analysis REF: 159 OBJ: 7
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. When the nurse using the Mini-Mental State Examination (MMSE) requests the patient to count by sevens (7, 14, 21, 28), the nurse is attempting to evaluate the patient’s:
a.
orientation.
b.
recall.
c.
ability to follow complex commands.
d.
attention and ability to perform calculations.
ANS: D
Counting by sevens tests a person’s ability for attention and calculation.
DIF: Cognitive Level: Analysis REF: 161, Figure 8-4
OBJ: 1 TOP: Mini-Mental State Examination
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
21. The nurse explains that the Minimum Data Set (MDS) 3.0 used in extended care facilities is designed to:
a.
identify ethnic populations in long-term care.
b.
group residents into specified activity levels.
c.
organize information relative to diagnostic categories.
d.
make assessment processes more consistent.
ANS: D
The MDS 3.0 is meant to standardize assessments and make them more reliable. MDS 3.0 is a computerized comprehensive assessment tool that justifies government funding.
DIF: Cognitive Level: Comprehension REF: 162 OBJ: 9
TOP: Minimum Data Set 3.0 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. The nurse explains that health screening can be conducted by __________. (Select all that apply.)
a.
a health professional
b.
telephone interview
c.
telecomputer
d.
pen and paper surveys
e.
lay persons
ANS: A, B, C, D
Lay persons may not do screenings unless they are specially trained. All other modes of screening are in use today.
DIF: Cognitive Level: Knowledge REF: 151 OBJ: 1
TOP: Health Screening Modes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. The nurse in a long-term care facility is aware that a health assessment will be __________. (Select all that apply.)
a.
the basis for the assignment of nursing diagnoses
b.
done only at admission to the facility
c.
performed only by a registered nurse
d.
a platform for the nursing care plan
e.
ongoing for the duration of the stay
ANS: A, D, E
The health assessment is done on admission to the facility and is ongoing during the duration of the stay. The initial assessment can be done by any licensed professional in the long-term facility and is the basis for the nursing diagnoses and plan of care.
DIF: Cognitive Level: Comprehension REF: 151 OBJ: 1
TOP: Health Assessment KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. The nurse collects objective data by way of __________. (Select all that apply.)
a.
observation
b.
patient complaints
c.
physical examination
d.
laboratory findings
e.
family input
ANS: A, C, D
Patient complaints and family input are subjective data. Objective data are concrete, observable signs.
DIF: Cognitive Level: Comprehension REF: 151 OBJ: 2
TOP: Objective Data Collection KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. The nurse planning a health interview with an older adult will take into consideration __________. (Select all that apply.)
a.
comfort of the physical setting
b.
methods to develop trust and rapport
c.
timing for minimal distractions
d.
the age and ethnicity of the patient
e.
income level
ANS: A, B, C, D
Income level is not a primary consideration in the health interview.
DIF: Cognitive Level: Comprehension REF: 152 OBJ: 4
TOP: Health Interview KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. The nurse taking identifying information will collect data pertinent to __________. (Select all that apply.)
a.
ethnicity
b.
previous or current occupation
c.
educational background
d.
perception of general health
e.
completion of advanced directives
ANS: A, B, C, E
The patient’s perception of his or her general health is subjective data in the health history and is not taken in the identifying data portion of the interview.
DIF: Cognitive Level: Comprehension REF: 154, Box 8-1
OBJ: 4 TOP: Identifying Data
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. The nurse uses the five techniques of physical health assessment, which include __________. (Select all that apply.)
a.
inspection
b.
palpation
c.
interview
d.
auscultation
e.
percussion
ANS: A, B, D, E
Interviewing is not a technique of physical assessment.
DIF: Cognitive Level: Knowledge REF: 155 OBJ: 7
TOP: Physical Assessment Techniques KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. When the nurse palpates a very weak pedal pulse in the right foot, the nurse would anticipate finding other indications of diminished peripheral circulation in the right foot and leg, such as __________. (Select all that apply.)
a.
bruising
b.
darkened color
c.
cool skin
d.
diminished hair on limb
e.
capillary refill of 3 seconds
ANS: C, D
A decreased arterial flow will produce a faint or absent pedal pulse, cool pale skin, and diminished hair on the limb. Bruising and a normal capillary refill time of 3 seconds are not indicators of impaired peripheral circulation.
DIF: Cognitive Level: Application REF: 157 OBJ: 5
TOP: Peripheral Circulation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. The nurse explains that the tool that allows the evaluation of core function in a resident in a long-term facility is the __________ __________ __________.
ANS: Minimum Data Set
DIF: Cognitive Level: Knowledge REF: 162 OBJ: 9
TOP: Minimum Data Set KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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