Medical Surgical Nursing 3rd Australian Edition by LeMone-Test Bank

 

 

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Sample Test

Chapter 03: Health History and Physical Examination

Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition

 

MULTIPLE CHOICE

 

1.    A man is admitted to the hospital with difficulty breathing. What is the best approach to obtain a health history?

a.	Obtain subjective data about the patient from his family members.
b.	Delay any subjective data collection, and focus only on his physical examination.
c.	Schedule several short sessions with the patient to gather necessary subjective data.
d.	Use the physician’s medical history as the primary source of subjective data.

 

 

ANS:  C

In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider’s medical history.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 40

OBJ:   4                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-1

 

2.    When the nurse is gathering information of a personal nature, which best demonstrates an acceptance of the patient’s behaviour?

a.	“Tell me, do you drink alcohol like I do?”
b.	“Many drugs used for hypertension cause sexual dysfunction. How is your sexual functioning?”
c.	“Most of my friends have been divorced. Would you like to tell me about the problems with your divorce?”
d.	“Many older people have limited financial resources for food and medications. Is this a concern for you?”

 

 

ANS:  D

When asking personal or potentially sensitive questions, prefacing the question with phrases such as “many people” indicates that the patient’s situation is normal. Therefore, the best response is the one in which the nurse asks whether the patient actually has the problem of limited resources but does not imply any judgments about the patient in this regard.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 39

OBJ:   2                    TOP:   Nursing Process: Implementation   MSC:  CRNE: NCP-1

 

3.    A patient is admitted to the orthopedic unit with a fractured right elbow following a skiing accident. During the initial nursing assessment, what information is related to the functional health pattern regarding the patient’s fractured elbow and the treatment he has received?

a.	Activity–exercise
b.	Cognitive–perceptual
c.	Self-perception–self-concept
d.	Health perception–health management

 

 

ANS:  D

In a hospitalized patient, the health perception–health management pattern includes information about the patient’s understanding of the onset and treatment of the current health problem.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 41, Table 3-3

OBJ:   2                    TOP:   Nursing Process: Planning              MSC:  CRNE: CH-9

 

4.    Which of the following findings is a positive sign in relation to a patient with an enlarged liver?

a.	Blood pressure of 128/78 mm Hg
b.	Pulse of 82 beats per minute
c.	Yellow-tinged sclera
d.	Painful and swollen great right toe

 

 

ANS:  C

A positive finding is one that indicates that the patient has or had the particular problem or sign under discussion. In this example, yellow-tinged sclera in a patient with an enlarged liver would indicate jaundice and be a positive sign.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 44

OBJ:   1                    TOP:   Nursing Process: Diagnosis             MSC:  CRNE: CH-8

 

5.    A patient reports that she has periodic fainting spells. In gathering more specific information, the nurse asks where these episodes most commonly occur. In what area is the nurse pursuing symptom investigation?

a.	Setting
b.	Frequency
c.	Chronology
d.	Associated manifestations

 

 

ANS:  A

Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 40

OBJ:   4                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-1

 

6.    The nurse records the following general survey of a patient: “The patient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” What additional information should be added to this general survey?

a.	Body movements
b.	Intake and output
c.	Reasons for contact with the health care system
d.	Comments of family members about his condition

 

 

ANS:  A

In addition to body movements, the general survey also describes the patient’s general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 44

OBJ:   4                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-1

 

7.    Following knee surgery, the patient has an elastic bandage applied to the surgical site. What examination technique is used to assess the patient’s distal extremity pulses and temperature?

a.	Palpation
b.	Inspection
c.	Percussion
d.	Auscultation

 

 

ANS:  A

Distal extremity pulses and temperature can be assessed only by palpation.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 44

OBJ:   3                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-4

 

8.    What does a negative finding obtained from the patient during the initial nursing history indicate?

a.	The patient is healthy.
b.	The symptom related to the specific health problem presented is delayed.
c.	The patient uses health promotion practices.
d.	A symptom normally associated with the patient’s health problem is absent.

 

 

ANS:  D

A negative finding is the absence of a sign or symptom that is usually associated with a problem, for example, if a patient with advanced liver disease has no peripheral edema.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 44

OBJ:   1                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-6

 

9.    As the nurse assesses the patient’s neck, the patient tells the nurse that it is so stiff she can hardly move it. The nurse should next perform a(n) _____ examination.

a.	emergency
b.	screening
c.	focused
d.	extensive

 

 

ANS:  C

The focused examination is needed when a patient has clinical manifestations that indicate a problem.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 48, Table 3-6

OBJ:   4                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-3

 

10.  When assessing using mediated percussion, which finger of which hand will the nurse use on the patient’s body?

a.	Middle finger of dominant hand
b.	Index finger of dominant hand
c.	Middle finger of nondominant hand
d.	Index finger of nondominant hand

 

 

ANS:  C

When performing mediated (indirect) percussion, the examiner uses the middle finger of the nondominant hand against the patient’s body for percussion.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 44

OBJ:   3                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-4

 

11.  Which functional health pattern is the nurse assessing when asking a patient how his or her family feels about the patient being hospitalized?

a.	Cognitive–perceptual
b.	Role–relationship
c.	Coping–stress tolerance
d.	Self-perception–self-concept

 

 

ANS:  B

The nurse is assessing the functional health pattern of role–relationships when asking a patient about how his or her family feels about the patient being hospitalized.

 

PTS:   1                    DIF:    Cognitive Level: Assessment          REF:   page 41, Table 3-3

OBJ:   2                    TOP:   Nursing Process: Implementation   MSC:  CRNE: CH-3

 

12.  Which part of the stethoscope is best to use when the nurse is listening to low-pitched sounds?

a.	Bell
b.	Tube
c.	Diaphragm
d.	The largest area for auscultation

 

 

ANS:  A

The bell of the stethoscope is best to listen to low-pitched sounds. The diaphragm (or largest part) is best used when assessing for high-pitched sounds.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 45

OBJ:   3                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-4

 

13.  While the nurse is taking a health history, the patient indicates that his father and grandfather both had heart attacks and were unable to be very active afterward. Which functional health pattern is reflected in this statement?

a.	Health perception–health management
b.	Coping–stress tolerance
c.	Cognitive–perceptual
d.	Activity–exercise

 

 

ANS:  A

The information in the patient statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception–health management pattern.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 42

OBJ:   2                    TOP:   Nursing Process: Planning              MSC:  CRNE: CH-9

 

14.  Which assessment technique would the nurse have used to document a finding of crepitus?

a.	Inspection
b.	Palpation
c.	Auscultation
d.	Percussion

 

 

ANS:  B

The use of light, moderate, and deep palpation can yield information related to masses, pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity, elasticity, vibration of voice sounds, crepitus, moisture, and differences in texture.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   page 44

OBJ:   3                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-4

 

Chapter 04: Patient and Caregiver Teaching

Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition

 

MULTIPLE CHOICE

 

1.    A patient is diagnosed with breast cancer following a needle biopsy of a breast lump. Considering the teaching process, what is the priority goal?

a.	Learning to live with the disease
b.	Selecting and using treatment options
c.	Preventing the recurrence of the tumour
d.	Minimizing the untoward effects of treatment

 

 

ANS:  B

Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to choose a treatment option. The other goals may be appropriate as treatment progresses.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 53, Table 4-1

OBJ:   2                    TOP:   Nursing Process: Planning              MSC:  CRNE: NCP-14

 

2.    After the nurse implements diet instruction with a patient with heart disease, the patient can explain the information but fails to make the recommended dietary changes. Which of the following statements best describes the nurse’s evaluation observation?

a.	The nursing responsibility has been fulfilled.
b.	Learning did not occur because the patient’s behaviour did not change.
c.	Choosing not to follow the diet is the learning behaviour that resulted.
d.	The instructional methods were not effective in helping the patient learn.

 

 

ANS:  C

Although the patient’s behaviour has not changed, the patient’s ability to explain the information indicates that learning has occurred and the patient is choosing at this time to continue with the previous diet. The patient may be in the contemplation or preparation state of the transtheoretical model of health behaviour change. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 54, Table 4-3

OBJ:   10                  TOP:   Nursing Process: Evaluation           MSC:  CRNE: NCP-14

 

3.    Which of the following is a recent health literacy tool that health care providers can use to identify patients who are at risk for low health literacy?

a.	Rapid Estimate of Adult Literacy in Medicine
b.	Newest Vital Sign
c.	Test of Functional Health Literacy in Adults
d.	Adult Literacy and Skills Survey

 

 

ANS:  B

Newest Vital Sign is the most recent health literacy tool; this test provides information about the patient that allows health care providers to adapt their communication practices in an effort to achieve better health outcomes.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   page 58

OBJ:   4                    TOP:   Nursing Process: Assessment          MSC:  CRNE: CH-7

 

4.    A patient admitted to the hospital with hyperglycemia and diagnosed with diabetes mellitus is scheduled for discharge the second day after admission. In view of the patient’s limited hospitalization, what should the nurse’s teaching plan emphasize first for the patient’s education about diabetes?

a.	Prioritize realistic goals that are essential to the patient’s immediate learning needs.
b.	Reflect a complete plan that can be implemented by home health care nurses.
c.	Use all available time to teach the patient as much as possible about the condition.
d.	Involve teaching the family instead of the patient about management of diabetes.

 

 

ANS:  A

When time is limited, the nurse should set realistic goals with the patient that can meet immediate needs. The patient and the family will need further teaching about the role of diet, exercise, medications, and so on, in controlling glucose, but these topics can be addressed through planning for appropriate referrals.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 55, Table 4-4

OBJ:   1                    TOP:   Nursing Process: Planning              MSC:  CRNE: CH-2

 

5.    When using the transtheoretical model of health behaviour change during patient teaching, the nurse listens to the patient state, “I told my wife that I was going to start exercising, and I think I will join a fitness club.” Which stage of change is this patient in?

a.	Action
b.	Preparation
c.	Termination
d.	Maintenance

 

 

ANS:  B

The patient’s statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 54, Table 4-3

OBJ:   6                    TOP:   Nursing Process: Evaluation           MSC:  CRNE: CH-19

 

6.    Which of the following nursing care plan entries would be a correctly worded nursing diagnosis?

a.	Ineffective knowledge
b.	Deficient knowledge
c.	Inappropriate knowledge
d.	Stereotypical knowledge

 

 

ANS:  B

A correctly worded and common nursing diagnosis for learning needs is deficient knowledge.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 60

OBJ:   6                    TOP:   Nursing Process: Diagnosis             MSC:  CRNE: CH-15

 

7.    A patient admits to the nurse that she does not read well. In developing a teaching plan for the patient, what does this information guide the nurse in determining?

a.	The degree of the patient’s motivation to learn
b.	What information the patient will be able to understand
c.	What instructional strategies should be used in teaching
d.	That the family must be included in the teaching process

 

 

ANS:  C

The information that the patient is illiterate indicates that the nurse should avoid the use of written materials in teaching and consider other instructional strategies in planning care for this patient.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 63

OBJ:   7                    TOP:   Nursing Process: Planning              MSC:  CRNE: NCP-14

 

8.    A postoperative patient says it hurts too much to breathe deeply and cough every two hours; the patient refuses to carry out the activity. Which is an appropriate intervention based on adult learning principles?

a.	Respect the patient’s wishes and turn the patient side to side instead but more frequently.
b.	Enlist the help of the physician in reinforcing the need to cough and breathe deeply.
c.	Explain what happens to the lungs postoperatively and why the exercise is important.
d.	Explain that it is the nurse’s responsibility to prevent complications and insist that she comply.

 

 

ANS:  C

Teaching the patient about the reason for the deep breathing and coughing will be likely to improve compliance and decrease the risk for complications. Adult learning principles indicate that adults learn best when they can use the information that they are learning immediately.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 53, Table 4-1

OBJ:   2                    TOP:   Nursing Process: Implementation   MSC:  CRNE: NCP-14

 

9.    Which following teaching strategy is most efficient, versatile, and economical to implement?

a.	Role play
b.	Print materials
c.	Lecture
d.	Discussion

 

 

ANS:  C

The lecture format is the most efficient, versatile, and economical teaching strategy that can be used when the amount of time is limited or when a group can benefit from acquiring a core of basic information.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 61

OBJ:   9                    TOP:   Nursing Process: Planning              MSC:  CRNE: NCP-14

 

10.  What should the nurse ask the patient, in order to assess readiness to learn before planning teaching activities?

a.	What are the patient’s living conditions and employment?
b.	What type of environment or activities help the patient to learn best?
c.	What information has been provided about the patient’s health problem?
d.	Does the patient have any beliefs that are inconsistent with the proposed treatment?

 

 

ANS:  C

Before implementing the teaching plan, the nurse should determine where the patient is in the stages of the change process, as the nurse may have to provide support and increase the patient’s awareness of the problem. The only way to do this is to assess what information has been provided to the patient about the health problem.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 60

OBJ:   6                    TOP:   Nursing Process: Assessment          MSC:  CRNE: NCP-14

 

11.  Which of the following is a technique to enhance patient learning?

a.	Keep patient expression of needs at a minimum.
b.	Focus on “nice to know” information initially.
c.	Emphasize relevancy of information to patient’s lifestyle.
d.	Maintain a formal physical environment at all times.

 

 

ANS:  C

Emphasizing the relevancy of the information to the patient’s lifestyle and suggesting how it may provide an immediate solution to a problem is a technique to enhance patient learning.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 63, Table 4-7

OBJ:   9                    TOP:   Nursing Process: Implementation   MSC:  CRNE: NCP-14

 

12.  The nurse is teaching a patient with peripheral vascular disease about foot care. Which is a correctly written specific learning objective for this patient?

a.	“The nurse will instruct the patient on appropriate foot care.”
b.	“Demonstrate the proper technique for trimming toenails to the patient.”
c.	“By discharge, the patient will list three ways to protect the feet from injury.”
d.	“The patient will understand the rationale for proper foot care after instruction.”

 

 

ANS:  C

This objective contains all four elements of a specific learning objective, namely, who will perform the activity, the actual behaviour, the conditions under which the behaviour is to be demonstrated, and the specific criteria that will be used to measure the patient’s success.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 60

OBJ:   8                    TOP:   Nursing Process: Planning              MSC:  CRNE: NCP-14

 

13.  Which of the following teaching strategies is most appropriate to promote use of coping skills by an adult patient?

a.	Lecture
b.	Role play
c.	Group teaching
d.	Printed materials

 

 

ANS:  B

Role play allows the patient to practise assertive behaviour and receive feedback about how the behaviour is perceived.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   page 62

OBJ:   9                    TOP:   Nursing Process: Implementation   MSC:  CRNE: NCP-14

 

14.  When completing the educational component of a general nursing assessment to prepare a teaching plan, which question is the best one to ask, initially?

a.	What is the patient’s level of motivation?
b.	What does the patient think is most important to learn first?
c.	Is the patient ready to learn?
d.	What does the patient already know?

 

 

ANS:  D

The initial question should be to ascertain what the patient already knows about the topic for which the teaching plan is being developed.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 56, Table 4-5

OBJ:   6                    TOP:   Nursing Process: Assessment          MSC:  CRNE: NCP-14

 

15.  How can the nurse most effectively evaluate a teaching objective of “the patient will select a 2000-mg sodium diet from the hospital menu daily for three days with 90% accuracy”?

a.	Ask the patient to identify what foods on the daily menu are high in sodium.
b.	Have the patient describe the foods that were consumed for the past three days, and total their sodium content.
c.	Note the food selected on three daily menus and determine whether the daily sodium content is within 1800 to 2200 mg.
d.	Use a record of the patient’s food intake for three days to determine whether the total sodium content is 6000 mg.

 

 

ANS:  C

The statement of the teaching objective is most clearly addressed with this answer, as the other answers do not directly address the objective as written.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   page 60

OBJ:   8                    TOP:   Nursing Process: Evaluation           MSC:  CRNE: CH-25