Health asses Part 2

• A patient comes to the health care provider's office for a visit. The patient has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? • Comprehensive assessment • Ongoing assessment • Focused assessment • Emergency assessment• A nurse has assessed a patient who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the patient admitted that his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse best respond to this assessment finding? • Identify a nursing diagnosis of Ineffective Health Maintenance. • Identify a collaborative problem that should involve the occupational therapist. • Make a referral to the unit's social work department. • Reassess the patient's blood glucose level. • The nurse is utilizing the Health Belief Model in the care of a patient whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? • The patient's motivation for change • The patient's medical comorbidities • The patient's learning style • The patient's prognosis for recovery • A nurse will complete an initial comprehensive assessment of a 60-year-old patient who is new to the clinic. What goal should the nurse identify for this type of assessment? • Identify the most appropriate forms of medical intervention for the patient. • Determine the most likely prognosis for the patient's health problem. • Identify the status of the patient's airway, breathing, and circulation. • Establish a baseline for the comparison of future health changes. • A nurse who provides care in a hospital setting is creating a plan of nursing care for a patient who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? • The patient's age • The unit's protocols • The patient's acuity • The nurse's potential for liability • A patient who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? • Review the patient's medication administration record for analgesic use. • Ask the patient about the most recent experiences of pain. • Meet with the patient's spouse and daughter to discuss the patient's pain. • Collaborate with the physician who is treating the patient.A nurse is preparing to assess a patient who is new to the clinic. When beginning the collection of the patient database, which of the following actions should the nurse prioritize? • Establishing a trusting relationship • Determining the patient's strengths • Identifying potential health problems • Making clinical inferences • A nurse is interpreting and validating information from an older adult patient who has been experiencing a functional decline. The nurse is in which phase of the interview? • Introductory • Working • Summary • Closing • A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? • “How often do your adult children typically visit you?” • “Your husband's death must have been very difficult for you.” • “You must quit smoking because it affects others, not only you.” • “How would you describe your feelings about getting older?” • A nurse is interviewing a 22-year-old patient of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? • Standing while the patient is seated • Using a moderate amount of eye contact • Sitting across the room from the patient • Minimizing facial expressions • A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted patient. Which of the following would the nurse identify as an example of a closed-ended question or statement? • “Tell me about your relationship with your children?” • “Tell me what you eat in a normal day?” • “Are you allergic to any medications?” • “What is your typical day like?” • A patient has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the patient's complaint? • Ignore the complaint for now and return to it later in the assessment. • Provide a laundry list of descriptive words. • Restate the question using simpler terms. • Wait in silence until the patient can determine the correct words. • A nurse is eliciting a patient's health history and the patient asks, “Can I take the herb ginkgo biloba with my other medications?” What action would be best if the nurse is unsure of the answer? • Promise to find out the information for the patient. • Change the subject and return to this topic later. • Teach the patient to only take prescribed medications. • Encourage the patient to ask the pharmacist or primary care provider. • The nurse is preparing to assess the mental status of a 90-year-old patient who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? • The patient's sensory abilities • The patient's general intelligence • The presence of any phobias • The patient's judgment and insight • A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a patient from a minority culture, the nurse has enlisted the assistance of a “culture broker.” How can this individual best facilitate the patient's care? • By interpreting the patient's language and culture • By evaluating the patient's culturally based health practices • By teaching the patient about health care • By making the patient feel comfortable and safe • Upon entering an exam room, the patient states, “Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!” Which response by the nurse would be most appropriate? • “Our schedule is very busy also. We got to you as soon as we could.” • “No one is forcing you to be here, and you are free to leave at any time.” • “Would you like to report your complaints to someone with power?” • “You're certainly justified in being upset, but I am ready to begin your exam now.” • A nurse has admitted a patient to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe? • “This helps us to complete your health record accurately.” • “This helps us to establish a trusting interpersonal relationship.” • “This helps us to evaluate the seriousness of your risk factors for disease.” • “This helps us have an appropriate focus for the physical examination.”• A clinic nurse has reviewed a new patient's available health record and will now begin taking the patient's health history. Which of the following questions should the nurse ask first when obtaining the health history? • “Do you have adequate health insurance coverage?” • “Are you generally fairly healthy?” • “What is your major health concern at this time?” • “Did you bring all your medications with you?” • A patient has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the “P”? • “What makes it worse?” • “When did it start?” • “How does it feel?” • “How would you rate your pain?” • A medical nurse has completed the review of systems component of the patient's health history. Which assessment finding should the nurse document under the review of systems? • “High school diploma plus 2 years of college” • “Caregiver reliable source of information” • “Menarche at age 13” • “Lungs clear to auscultation bilaterally” • A patient has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the patient's nutritional status? • Ask the patient to explain MyPlate. • Obtain a 24-hour diet recall. • Ask about the contents of one typical meal. • Elicit the patient's favorite foods. • A patient's elevated body mass index (BMI) has prompted the nurse to assess the patient's activity and exercise level. Which statement would indicate to the nurse that the patient is getting the recommended amount of exercise? • “I walk briskly on the treadmill once or twice a week.” • “I play basketball with a team every Friday night without fail.” • “I go to a step class for an hour three times a week.” • “I swim for at least half an hour each Saturday morning.”• During an assessment, the nurse determines that a patient sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a patient's current medication regimen? • Ask the patient to identify which medications taken every day. • Ask the patient to bring all the medications and supplements to an interview. • Ask the caregiver whether the patient is taking prescribed medications. • Ask the patient about the use of any over-the-counter medications. • The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? • “Do you always wear your seatbelt when driving?” • “How much beer, wine, or alcohol do you drink?” • “Do you use condoms with each sexual encounter?” • “Could you describe how you perform self-breast exams?” • A nurse is creating a genogram of a patient's family health history. The nurse should use which of the following symbols to denote the patient's female relatives? • Circle • Square • Triangle • Rectangle