Medical surgical Nursing Assessment and Management Of Clinical Problems, 8th Edition by Sharon L. Lewis – Test Bank
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Lewis:
Medical-Surgical Nursing, 8th Edition
Chapter 3: Health
History and Physical Examination
Test Bank
MULTIPLE CHOICE
1. A patient who is
having difficulty breathing is admitted to the hospital. The best approach
for the nurse to use
to obtain a complete health history is to
a. obtain subjective
data about the patient from family members.
b. omit subjective
data collection and obtain the physical examination.
c. use the health care
provider’s medical history to obtain subjective data.
d. schedule several
short sessions with the patient to gather subjective data.
ANS: D
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. Family
members may be able to provide some subjective data, but only the
patient will be able
to give subjective information about the shortness of breath. Since the
subjective data about
the patient’s respiratory status will be essential, obtaining the
physical examination
alone will not provide sufficient information.
DIF: Cognitive Level:
Application REF: 38
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
2. Immediate surgery
is planned for a patient with acute abdominal pain. The question used
by the nurse that will
elicit the most complete information about the patient’s copingstress
tolerance pattern is
a. “Can you tell me
how intense your pain is now?”
b. “What do you think
caused this abdominal pain?”
c. “How do you feel
about yourself and your hospitalization?”
d. “Are there other
major problems that are a concern right now?”
ANS: D
The coping-stress
tolerance pattern includes information about other major stressors
confronting the
patient. The health perception–health management pattern includes
information about the
patient’s ideas about risk factors. Feelings about self and the
hospitalization are
assessed in the self-perception–self-concept pattern. Intensity of pain
is part of the
cognitive-perceptual pattern.
DIF: Cognitive Level:
Comprehension REF: 41-42
TOP: Nursing Process:
Assessment MSC: NCLEX: Psychosocial Integrity
3. During the health
history interview, a patient tells the nurse about periodic fainting spells.
Which question by the
nurse will be most helpful in determining the setting in which the
fainting spells occur?
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3-2
a. “How frequently do
you have the fainting spells?”
b. “Where are you when
you have the fainting spells?”
c. “Do the spells tend
to occur at any special time of day?”
d. “Do you have any
other symptoms along with the spells?”
ANS: B
Information about the
setting is obtained by asking where the patient was and what the
patient was doing when
the symptom occurred. The other questions from the nurse are
appropriate for
obtaining information about chronology, frequency, and associated
clinical
manifestations.
DIF: Cognitive Level:
Comprehension REF: 39
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
4. 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.” Additional information that should be
added to this general
survey includes
a. nutritional status.
b. intake and output.
c. reasons for contact
with the health care system.
d. comments of family
members about his condition.
ANS: A
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.
DIF: Cognitive Level:
Application REF: 44
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
5. A nurse is
performing a health history and physical examination for a patient with
rightsided
rib fractures. The
pertinent negative finding is that the patient
a. states that there
have been no other health problems recently.
b. denies having pain
when the area over the fractures is palpated.
c. has several bruised
and swollen areas on the right anterior chest.
d. refuses to take a
deep breath because of the associated chest pain.
ANS: B
The nurse expects that
a patient with rib fractures will have pain over the fractured area.
The first statement is
neither a positive nor a negative finding with regard to the rib
fractures. The
bruising and swelling and pain with breathing are positive findings.
DIF: Cognitive Level: Application
REF: 42
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
6. As the nurse
assesses the patient’s neck, the patient says, “My neck is so stiff I can
hardly
move it.” This finding
indicates the nurse should perform a(n)
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3-3
a. focused assessment.
b. screening
assessment.
c. emergency
assessment.
d. comprehensive
assessment.
ANS: A
The focused assessment
is needed when a patient has clinical manifestations that indicate
a problem. An
emergency assessment is done when the nurse needs to obtain information
about life-threatening
problems quickly while simultaneously taking action to maintain
vital function. The
screening examination or assessment is used to assess for possible
problems such as
colorectal cancer in patients who are age 50 or older. A comprehensive
assessment is a
detailed health history and physical examination.
DIF: Cognitive Level:
Application REF: 45-46
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is
preparing to perform a focused abdominal assessment for a patient who has
high-pitched bowel
sounds. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
ANS: B
A stethoscope is used
to auscultate bowel sounds. The other equipment may be used for a
comprehensive
assessment, but will not be needed for a focused abdominal assessment.
DIF: Cognitive Level:
Comprehension REF: 43 | 45
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
8. When the nurse is
planning for the physical examination of an alert 86-year-old patient,
adaptations to the
examination technique should include
a. speaking slowly
when directing the patient.
b. avoiding the use of
touch as much as possible.
c. using slightly more
pressure for palpation of the liver.
d. organizing the
sequence to minimize position changes.
ANS: D
Older patients may
have age-related changes in mobility that make it more difficult to
change position. There
is no need to avoid the use of touch when examining older
patients. Less
pressure should be used over the liver. Since the patient is alert, there is no
indication that there
is any age-related difficulty in understanding directions from the
nurse.
DIF: Cognitive Level:
Application REF: 45
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
Test Bank
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3-4
9. While the nurse is
taking the health history, a patient states, “My father and grandfather
both had heart attacks
and were unable to be very active afterwards.” This statement is
related to the
functional health pattern of
a. activity-exercise.
b.
cognitive-perceptual.
c. coping-stress
tolerance.
d. health
perception–health management.
ANS: D
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
maintenance pattern.
DIF: Cognitive Level:
Comprehension REF: 40-41
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
10. A patient is seen
in the emergency department with chest pain and hypotension. Which
type of assessment
should the nurse do at this time?
a. Focused assessment
b. Subjective
assessment
c. Emergency
assessment
d. Comprehensive
assessment
ANS: C
Since the patient is
hemodynamically unstable, an emergency assessment is needed.
Comprehensive and
focused assessments may be needed after the patient is stabilized.
Subjective information
is needed, but objective data such as vital signs also are essential
for the unstable
patient.
DIF: Cognitive Level:
Comprehension REF: 46
TOP: Nursing Process:
Assessment MSC: NCLEX: Health Promotion and Maintenance
11. When caring for a
patient who was admitted a few hours previously with nausea and
vomiting, which
nursing action can the RN delegate to an LPN/LVN?
a. Ask the patient
about any current nausea.
b. Finish documenting
the admission assessment.
c. Determine the
patient’s priority nursing diagnoses.
d. Obtain the health
history from the patient’s caregiver.
ANS: A
The RN may delegate
parts of the focused assessment to an LPN/LVN. Obtaining the
health history,
documentation of the admission assessment, and determining nursing
diagnoses require RN
education and scope of practice.
DIF: Cognitive Level:
Application REF: 46
OBJ: Special
Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and
Effective Care Environment
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3-5
12. When assessing the
circulation to the lower leg of a patient who has had knee surgery,
which action should
the nurse take first?
a. Feel for the
temperature of the foot.
b. Visually inspect
the color of the foot.
c. Check the patient’s
pedal pulses using the fingertips.
d. Compress the nail
beds to determine capillary refill time.
ANS: B
Inspection is the
first of the major techniques used in the physical examination. Palpation
and auscultation are
used later in the examination.
DIF: Cognitive Level:
Application REF: 43
OBJ: Special
Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health
Promotion and Maintenance
13. When assessing a
patient’s abdomen during the admission assessment, which of these
actions should the
nurse take first?
a. Feel for any
masses.
b. Palpate the
abdomen.
c. Percuss the liver
borders.
d. Listen to the bowel
sounds.
ANS: D
When assessing the
abdomen, auscultation is done before palpation or percussion because
palpation and
percussion can cause changes in bowel sounds and alter the findings. All of
the techniques are
appropriate, but auscultation should be done first.
DIF: Cognitive Level:
Comprehension REF: 43
OBJ: Special
Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health
Promotion and Maintenance
14. When admitting a
patient who has just arrived on the medical unit with severe abdominal
pain, what should the
nurse do first?
a. Complete only basic
demographic data before addressing the patient’s abdominal
pain.
b. Medicate the
patient for the abdominal pain before attending to the health history
and examination.
c. Inform the patient
that the abdominal pain will be treated as soon as the health
history is completed.
d. Take the initial
vital signs and then deal with the abdominal pain before
completing the health
history.
ANS: D
The patient priority in
this situation will be to decrease the pain level because the patient
will be unlikely to
cooperate in providing demographic data or the health history until the
nurse addresses the
pain. However, obtaining information about vital signs is essential
before using either
pharmacologic or nonpharmacologic therapies for pain control. The
vital signs may
indicate hemodynamic instability that would need to be addressed
immediately.
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3-6
DIF: Cognitive Level:
Application REF: 39
OBJ: Special
Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX:
Physiological Integrity
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Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 4: Patient and Caregiver Teaching
Test Bank
MULTIPLE CHOICE
1. A patient with newly diagnosed breast cancer has a nursing diagnosis of
deficient
knowledge about breast cancer. When the nurse is planning teaching for the
patient,
which is the most important initial learning goal?
a. The patient will select the most appropriate breast cancer therapy.
b. The patient will state ways of preventing the recurrence of the tumor.
c. The patient will demonstrate coping skills needed to manage the disease.
d. The patient will choose methods to minimize adverse effects of treatment.
ANS: A
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.
DIF: Cognitive Level: Application REF: 50 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
2. After the nurse implements diet instruction for a patient with heart
disease, the patient
can explain the information but fails to make the recommended dietary changes.
The
nurse’s evaluation is that
a. learning did not occur because the patient’s behavior did not change.
b. choosing not to follow the diet is the behavior that resulted from learning.
c. the nursing responsibility for helping the patient make dietary changes has
been
fulfilled.
d. the teaching methods were ineffective in helping the patient learn the
dietary
information.
ANS: B
Although the patient behavior 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 in the Transtheoretical Model. The nurse should reinforce the need for
change and
continue to provide information and assistance with planning for change.
DIF: Cognitive Level: Application REF: 50-51 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Health Promotion and Maintenance
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Elsevier, Inc.
4-2
3. A 43-year-old is diagnosed with type 2 diabetes mellitus after being
admitted to the
hospital with an infected foot wound. When applying principles of adult
learning, which
teaching strategy by the nurse is most likely to be effective?
a. Discuss the importance of blood glucose control in maintenance of long-term
health.
b. Demonstrate the correct method for cleaning and redressing the wound to the
patient.
c. Assure the patient that the nurse is an expert on management of diabetes
complications.
d. Wait until after discharge and have a home health nurse teach about foot
care and
diabetes management.
ANS: B
Principles of adult education indicate that readiness and motivation to learn
are high
when facing new tasks (such wound care) and when demonstration and practice of
skills
are available. Although a home health referral may be needed for this patient,
teaching
should not be postponed until discharge. Adult learners are independent; the
nurse should
act as a facilitator for learning, rather than as the expert. Adults learn best
when the topic
is of immediate usefulness; long-term goals may not be very motivating.
DIF: Cognitive Level: Application REF: 50 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
4. A patient admitted to the hospital with hyperglycemia and newly diagnosed
diabetes
mellitus is scheduled for discharge the second day after admission. When
implementing
patient teaching, which is the best action for the nurse to take?
a. Instruct about the increased risk for cardiovascular disease.
b. Provide detailed information about dietary control of glucose.
c. Teach glucose self-monitoring and medication administration.
d. Give information about the effects of exercise on glucose control.
ANS: C
When time is limited, the nurse should focus on the priorities of teaching. In
this
situation, the patient should know how to test blood glucose and administer
medications
to control glucose levels. The patient will need further teaching about the
role of diet,
exercise, various medications, and the many potential complications of
diabetes, but these
topics can be addressed through planning for appropriate referrals.
DIF: Cognitive Level: Application REF: 52
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and
Maintenance
5. When using the Transtheoretical Model of Health Behavior Change during
patient
teaching, the nurse identifies that the patient who states, “I told my wife
that I was going
to start exercising, and I think I will join a fitness club,” is in the stage
of
a. preparation.
b. termination.
c. maintenance.
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4-3
d. contemplation.
ANS: A
The patient’s statement indicating that the plan for change is being shared
with someone
else indicates that the preparation stage has been achieved. Contemplation of a
change
would be indicated by a statement like “I know I should exercise.” Maintenance
of a
change occurs when the patient practices the behavior regularly. Termination
would be
indicated when the change is a permanent part of the lifestyle.
DIF: Cognitive Level: Comprehension REF: 50-51
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. While admitting a patient to the medical unit, the nurse learns that the
patient does not
read well. This information will guide the nurse in determining
a. the degree of patient motivation and readiness to learn.
b. what information the patient will be able to understand.
c. that the family must be included in the teaching process.
d. which instructional strategies should be used in teaching.
ANS: D
The information that the patient is illiterate indicates that the nurse should
avoid the use
of written materials in teaching and choose other strategies. The patient does
not indicate
a lack of motivation or an inability to understand new information. The
patient’s lack of
reading ability does not necessarily imply that the family must be included in
the teaching
process.
DIF: Cognitive Level: Comprehension REF: 54 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
7. When assessing the learning needs for a patient who has coronary heart
disease, the nurse
finds that the patient has recently made dietary changes to decrease fat intake
and has
stopped smoking. The best initial statement by the nurse at this time is
a. “Although those are important, it is essential that you make other changes,
too.”
b. “Are you having any difficulty in maintaining the changes you have already
made?”
c. “You have already accomplished some changes that are important in heart
health.”
d. “Which additional changes in your lifestyle would you like to implement at
this
time?”
ANS: C
Positive reinforcement of the learner’s achievements is critical in making
lifestyle
changes. This patient is in the action stage of the Transtheoretical Model,
when
reinforcement of the changes being made is an important nursing intervention.
The other
responses are also appropriate, but are not the best initial response.
DIF: Cognitive Level: Application REF: 51 | 55
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and
Maintenance
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4-4
8. To assess a patient’s readiness to learn before planning teaching
activities, which
question should the nurse ask?
a. “What kind of work and leisure activities do you do?”
b. “What information do you think you need right now?”
c. “Do you have any religious beliefs that are inconsistent with the
treatment?”
d. “Can you describe the types of activities that help you learn new information?”
ANS: B
Motivation and readiness to learn depend on what the patient values and
perceives as
important. The other questions are also important in developing the teaching
plan, but do
not address what information most interests the patient at present.
DIF: Cognitive Level: Application REF: 55
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
9. The nurse develops a nursing diagnosis of ineffective health maintenance
related to low
motivation based on the finding that the diabetic patient
a. does not perform capillary blood glucose tests as directed.
b. occasionally forgets to take the daily prescribed medication.
c. says that dietary intake does not seem to impact fatigue level.
d. cannot identify signs or symptoms of high and low blood glucose.
ANS: C
The patient’s motivation to follow a diabetic diet will be decreased if the
patient feels that
dietary changes do not impact symptoms. The other responses do not indicate
that the
ineffective health maintenance is caused by lack of motivation.
DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process:
Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
10. A patient with poor circulation to the feet requires teaching about foot
care. Which
learning goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will list three ways to protect the feet from injury by
discharge.
c. The nurse will instruct the patient on appropriate foot care before
discharge.
d. The patient will understand the rationale for proper foot care after
instruction.
ANS: B
Learning goals should state clear, measurable outcomes of the learning process.
Options a
and c describe actions that the nurse will take, rather than behaviors that
indicate that
patient learning has occurred. Option d is too vague and nonspecific to measure
whether
learning has occurred.
DIF: Cognitive Level: Application REF: 55-56 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
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4-5
11. When the nurse is planning teaching for a patient who needs to improve
skills in being
more assertive, the most effective teaching strategy will be
a. role playing.
b. peer teaching.
c. printed materials.
d. lecture-discussion.
ANS: A
Role-playing allows the patient to practice assertive behavior and receive
feedback about
how the behavior is perceived. Lecture-discussion, peer-teaching, and printed
materials
are more useful for other learning needs.
DIF: Cognitive Level: Comprehension REF: 57 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
12. The patient’s teaching plan includes this goal: “The patient will select a
2-gram sodium
diet from the hospital menu for the next 3 days.” Which evaluation method will
be best
for the nurse to use when determining whether teaching was effective?
a. Check the sodium content of the patient’s menu choices over the next 3 days
b. Ask the patient to identify which foods on the hospital menus are high in
sodium.
c. Have the patient list favorite foods that are high in sodium and foods that
could be
substituted for these favorites.
d. Compare the patient’s sodium intake over the next 3 days with the sodium
intake
before the teaching was implemented.
ANS: A
All of the answers address the patient’s sodium intake, but the desired patient
behaviors
in the learning objective are most clearly addressed by evaluation of the
patient’s menu
choices.
DIF: Cognitive Level: Application REF: 58-59 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Health Promotion and Maintenance
13. The nurse is preparing written handouts to be used as part of the
standardized teaching
plan for patients who have been recently diagnosed with diabetes. Which of the
following
statements would be appropriate to include in the handouts?
a. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes
mellitus.
b. The use of the right foods can help in keeping blood glucose at a
near-normal
level.
c. Some diabetics control blood glucose with oral medications or nutritional
interventions.
d. Diabetes mellitus is characterized by chronic hyperglycemia and the
associated
symptoms.
ANS: B
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4-6
Reading level for patient teaching materials should be at the 5th grade level.
The other
responses have words with three or more syllables, use many medical terms,
and/or are
too long.
DIF: Cognitive Level: Application REF: 56 | 58 TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse in the hospital has implemented a teaching plan to assist a
patient with
rheumatoid arthritis in accomplishing daily activities independently. To
evaluate the
patient’s long-term response to the teaching, the best action by the nurse will
be to
a. make a referral to the home health nursing department for home visits.
b. check the patient’s ability to bathe without any assistance the next day.
c. have the patient demonstrate the learned skills at the end of the teaching
session.
d. arrange a physical therapy visit before the patient is discharged from the
hospital.
ANS: A
The patient’s long-term response may need to be assessed after discharge; a
home health
referral would allow this to occur. The other actions allow evaluation of the
patient’s
short-term response to teaching.
DIF: Cognitive Level: Application REF: 58-59 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Health Promotion and Maintenance
15. When assessing a 22-year-old male patient, the nurse learns that he smokes
a pack of
cigarettes daily. The patient tells the nurse, “I enjoy smoking and have no
plans to quit.”
Which nursing diagnosis is most appropriate?
a. Health seeking behaviors related to cigarette use
b. Ineffective health maintenance related to tobacco use
c. Readiness for enhanced self-health management related to smoking
d. Deficient knowledge related to long-term effects of cigarette smoking
ANS: B
The patient’s statement indicates that he is not considering smoking cessation.
Ineffective
health maintenance is defined as the inability to identify, manage, and/or seek
out help to
maintain health.
DIF: Cognitive Level: Application REF: 55 TOP: Nursing Process:
Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
16. A 73-year-old Hispanic/Latino patient is seen at the health clinic and
diagnosed with
protein malnutrition. The priority action in the nurse’s teaching plan will be
to
a. suggest the use of liquid supplements as a way to increase protein intake.
b. encourage the patient to increase the dietary intake of meat, cheese, and
milk.
c. ask the patient to record the intake of all foods and beverages for a 3-day
period.
d. focus on the use of combinations of beans and rice to improve daily protein
intake.
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4-7
ANS: C
Assessment is the first step in assisting a patient with health changes. The
other answers
may be appropriate for the patient, but the nurse will not be able to determine
this until
the assessment of the patient is complete.
DIF: Cognitive Level: Application REF: 53
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
17. A newly diagnosed diabetic patient tells the nurse, “I want to know how to
give my own
insulin.” Which action will the nurse take first when implementing the
standardized
diabetic teaching plan?
a. Demonstrate how to draw up and administer insulin.
b. Discuss the use of exercise to decrease insulin needs.
c. Teach about differences between the various types of insulin.
d. Provide handouts about therapeutic and adverse effects of insulin.
ANS: A
Adult education is most effective when focused on information that the patient
thinks is
needed right now. All of the indicated information will need to be included
when
planning teaching for this patient, but the teaching will be most effective if
the nurse
starts with the patient’s stated priority topic.
DIF: Cognitive Level: Application REF: 50 | 55
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
18. Which action should the nurse take first when teaching a patient’s spouse
how to manage
the blood pressure (BP) for a patient with newly diagnosed high BP?
a. Teach the caregiver how to take the patient’s BP using a manual blood
pressure
cuff.
b. Have the dietician meet with the patient and caregiver to discuss low sodium
dietary choices.
c. Ask the patient and caregiver to select important information from a list of
hypertension teaching topics.
d. Provide written information about treatment and complications of
hypertension for
the patient and caregiver.
ANS: C
Since adults learn best when given information that they view as being needed
immediately, asking the caregiver and patient to prioritize learning needs is
likely to be
the most successful approach to home management of health problems. The other
actions
also may be appropriate, depending on what learning needs the caregiver and
patient
have, but the initial action should be to assess what the learners feel is
important.
DIF: Cognitive Level: Application REF: 50 | 53
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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