Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis – Test Bank
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Sample Test
Chapter 03: Health History and Physical Examination
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A
patient who is actively bleeding is admitted to the emergency department. Which
approach is best for
the nurse to use to obtain a health history?
|
a. |
Briefly interview the
patient while obtaining vital signs. |
|
b. |
Obtain subjective data
about the patient from family members. |
|
c. |
Omit subjective data
collection and obtain the physical examination. |
|
d. |
Use the health care
provider’s medical history to obtain subjective data. |
ANS: A
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 bleeding. Because the subjective data
about the cause of the patient’s bleeding will be essential, obtaining the
physical examination alone will not provide sufficient information.
DIF: Cognitive Level: Apply
(application)
REF: 40
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
2. Immediate
surgery is planned for a patient with acute abdominal pain. Which question by
the nurse will elicit the most complete
information about the patient’s coping-stress tolerance pattern?
|
a. |
“Can you rate your pain on
a 0 to 10 scale?” |
|
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: Apply
(application)
REF: 37
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 best elicit any associated
clinical manifestations?
|
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: D
Asking about other associated symptoms will provide the nurse
more information about all the clinical manifestations related to the fainting
spells. 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 and frequency.
DIF: Cognitive Level: Apply
(application)
REF: 35
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
50-yr-old Asian female attended by her husband 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 the nurse add to this general
survey?
|
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: Understand
(comprehension)
REF: 39
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
5. A
nurse performs a health history and physical examination with a patient who has
a right leg fracture. Which assessment would be a pertinent negative finding?
|
a. |
Patient has several bruised
and swollen areas on the right leg. |
|
b. |
Patient states that there
have been no other recent health problems. |
|
c. |
Patient refuses to bend the
right knee because of the associated pain. |
|
d. |
Patient denies having pain
when the area over the fracture is palpated. |
ANS: D
The nurse expects that a patient with a leg fracture will have
pain over the fractured area. The bruising and swelling and pain with bending
are positive findings. Having no other recent health problems is neither a
positive nor a negative finding with regard to a leg fracture.
DIF: Cognitive Level: Apply
(application)
REF: 39
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
6. The
nurse who is assessing an older adult with rectal bleeding asks, “Have you ever
had a colonoscopy?” The nurse is performing what type of assessment?
|
a. |
Focused assessment |
c. |
Detailed health assessment |
|
b. |
Emergency assessment |
d. |
Comprehensive assessment |
ANS: A
A focused assessment is an abbreviated assessment used to
evaluate the status of previously identified problems and monitor for signs of
new problems. It can be done when a specific problem is identified. 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. A comprehensive assessment includes a detailed health
history and physical examination of one body system or many body systems. It is
typically done on admission to the hospital or onset of care in a primary care
setting.
DIF: Cognitive Level: Understand
(comprehension)
REF: 40
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
7. The
nurse is preparing to perform a focused assessment for a patient complaining of
shortness of breath. Which equipment will be needed?
|
a. |
Flashlight |
c. |
Tongue blades |
|
b. |
Stethoscope |
d. |
Percussion hammer |
ANS: B
A stethoscope is used to auscultate breath sounds. The other
equipment may be used for a comprehensive assessment but will not be needed for
a focused respiratory assessment.
DIF: Cognitive Level: Understand
(comprehension)
REF: 40
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
8. The
nurse plans to complete a physical examination of an alert, older patient.
Which adaptations to the examination technique should the nurse include?
|
a. |
Avoid the use of touch as
much as possible. |
|
b. |
Use slightly more pressure
for palpation of the liver. |
|
c. |
Speak softly and slowly
when talking with the patient. |
|
d. |
Organize the sequence to
minimize the 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. Because the patient is alert, there is no indication that there is any
age-related difficulty in understanding directions from the nurse.
DIF: Cognitive Level: Apply
(application)
REF: 40
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
9. While
the nurse is taking the health history, a patient states, “My mother and sister
both had double mastectomies and were unable to be very active for weeks.”
Which functional health pattern is represented by this patient’s statement?
|
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
and important information about the family history. Identification of risk
factors falls into the health perception–health maintenance pattern.
DIF: Cognitive Level: Understand
(comprehension)
REF: 37
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
10. A
patient is seen in the emergency department with severe abdominal pain and
hypotension. Which type of assessment should the nurse do at this time?
|
a. |
Focused assessment |
c. |
Emergency assessment |
|
b. |
Subjective assessment |
d. |
Comprehensive assessment |
ANS: C
Because 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 are essential for the unstable patient.
DIF: Cognitive Level: Understand
(comprehension)
REF: 40
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
11. The registered
nurse (RN) cares for a patient who was admitted a few hours previously with
back pain after falling. Which action can the RN delegate to unlicensed
assistive personnel (UAP)?
|
a. |
Finish documenting the
admission assessment. |
|
b. |
Determine the patient’s
priority nursing diagnoses. |
|
c. |
Obtain the health history
from the patient’s caregiver. |
|
d. |
Take the patient’s
temperature, pulse, and blood pressure. |
ANS: D
The RN may delegate vital signs to the UAP. Obtaining the health
history, documentation of the admission assessment, and determining nursing
diagnoses require the education and scope of practice of the RN.
DIF: Cognitive Level: Apply
(application)
REF: 36
OBJ: Special Questions: Delegation
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. When
assessing for formation of a possible blood clot in the lower leg of a patient,
which action should the nurse take first?
|
a. |
Visually inspect the leg. |
|
b. |
Feel for the temperature of
the leg. |
|
c. |
Check the patient’s pedal
pulses using the fingertips. |
|
d. |
Compress the nail beds to
determine capillary refill time. |
ANS: A
Inspection is the first of the major techniques used in the
physical examination. Palpation and auscultation are then used later in the
examination.
DIF: Cognitive Level: Apply
(application)
REF: 39
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 action
should the nurse take first?
|
a. |
Feel for any masses. |
c. |
Listen for bowel sounds. |
|
b. |
Palpate the abdomen. |
d. |
Percuss the liver borders. |
ANS: C
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: Understand
(comprehension)
REF: 39
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 unit with a severe headache,
what should the nurse do first?
|
a. |
Complete only basic
demographic data before addressing the patient’s pain. |
|
b. |
Inform the patient that the
headache will be treated as soon as the health history is completed. |
|
c. |
Medicate the patient for
the headache before doing the health history and examination. |
|
d. |
Take the initial vital
signs and then address the headache before completing the health history. |
ANS: C
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.
DIF: Cognitive Level: Apply
(application)
REF: 35
OBJ: Special Questions:
Prioritization TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiological Integrity
OTHER
1. In
what order will the nurse perform these actions when doing a physical
assessment for a patient admitted with abdominal pain? (Put a comma and a space between
each answer choice [A, B, C, D].)
2. Percuss
the abdomen to locate any areas of dullness.
3. Palpate
the abdomen to check for tenderness or masses.
4. Inspect
the abdomen for distention or other abnormalities.
5. Auscultate
the abdomen for the presence of bowel sounds.
ANS:
C, D, A, B
When assessing the abdomen, the initial action is to inspect the
abdomen. Auscultation is done next because percussion and palpation can alter
bowel sounds and produce misleading findings.
DIF: Cognitive Level: Understand
(comprehension)
REF: 39
TOP: Nursing Process:
Assessment MSC:
NCLEX: Physiological Integrity
Chapter 04: Patient and Caregiver Teaching
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A
patient with newly diagnosed colon cancer has a nursing diagnosis of deficient
knowledge about colon cancer. The nurse should initially focus
on which learning goal for this patient?
|
a. |
The patient will state ways
of preventing the recurrence of the cancer. |
|
b. |
The patient will explore
and select an appropriate colon cancer therapy. |
|
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: 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 explore and choose a treatment option. The other goals may be
appropriate as treatment progresses.
DIF: Cognitive Level: Apply
(application)
REF: 47
TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
2. After
the nurse provides diet instructions for a patient with diabetes, the patient
can restate the information but fails to make the recommended diet changes. How
would the nurse best evaluate
the patient’s situation?
|
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 nurse’s responsibility
for helping the patient make diet changes has been fulfilled. |
|
d. |
The teaching methods were
ineffective in helping the patient learn about the necessary diet changes. |
ANS: B
Although the patient behavior has not changed, the patient’s
ability to restate the information indicates that learning has occurred, and
the patient is choosing at this time not to change the diet. The patient may be
in the contemplation or preparation stage 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: Apply
(application)
REF: 47
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
3. A
patient is diagnosed with heart failure after being admitted to the hospital
for shortness of breath and fatigue. Which teaching strategy, if implemented by
the nurse, is most likely
to be effective?
|
a. |
Assure the patient that the
nurse is an expert on management of heart failure. |
|
b. |
Teach the patient at each
meal about the amounts of sodium in various foods. |
|
c. |
Discuss the importance of
medication control in maintenance of long-term health. |
|
d. |
Refer the patient to a home
health nurse for instructions on diet and fluid restrictions. |
ANS: B
Principles of adult education indicate that readiness and
motivation to learn are high when facing new tasks (e.g., learning about the
sodium amounts in various food items) 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: Apply
(application)
REF: 47
TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
4. A
patient who was admitted to the hospital with hyperglycemia and newly diagnosed
diabetes mellitus is scheduled for discharge the second day after admission.
When implementing patient teaching, what is the priority action
for the nurse?
|
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: Apply
(application)
REF: 49
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. A
patient states, “I told my husband I wouldn’t buy as much prepared food snacks,
so I will go the grocery store to buy fresh fruit, vegetables, and whole
grains.” When using the Transtheoretical Model of Health Behavior Change, the
nurse identifies that this patient is in which stage of change?
|
a. |
Preparation |
c. |
Maintenance |
|
b. |
Termination |
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: Understand
(comprehension)
REF: 48
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
6. While
admitting a patient to the medical unit, the nurse determines that the patient
has a hearing impairment. How should the nurse use this information to plan
teaching and learning strategies?
|
a. |
Motivation and readiness to
learn will be affected. |
|
b. |
The family must be included
in the teaching process. |
|
c. |
The patient will have
problems understanding information. |
|
d. |
Written materials should be
provided with verbal instructions. |
ANS: D
The information that the patient has a hearing impairment
indicates that the nurse should use written and verbal materials in teaching
along with other strategies. The patient does not indicate a lack of motivation
or an inability to understand new information. The patient’s decreased hearing
does not necessarily imply that the family must be included in the teaching
process.
DIF: Cognitive Level: Understand
(comprehension)
REF: 51
TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
7. A
patient who is morbidly obese states, “I’ve recently made some changes in my
life. I’ve decreased my fat intake, and I’ve stopped smoking.” Which statement,
if made by the nurse, is the best initial
response?
|
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. |
“Which additional changes
in your lifestyle would you like to implement at this time?” |
|
d. |
“You have already
accomplished changes that are important for the health of your heart.” |
ANS: D
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: Apply
(application)
REF: 53
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
8. The
nurse is planning a teaching session with a patient newly diagnosed with
migraine headaches. To assess a patient’s readiness to learn, which question
should the nurse ask first?
|
a. |
“What kind of work and
leisure activities do you do?” |
|
b. |
“What information do you
think you need right now?” |
|
c. |
“Can you describe the types
of activities that help you learn new information?” |
|
d. |
“Do you have any religious
beliefs that are inconsistent with the planned treatment?” |
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: Apply
(application)
REF: 53
TOP: Nursing Process:
Assessment MSC:
NCLEX: Health Promotion and Maintenance
9. The
nurse considers a nursing diagnosis of ineffective health maintenance related
to low motivation for a patient with diabetes. Which finding would the
nurse most likely
use to support this nursing diagnosis?
|
a. |
The patient does not
perform capillary blood glucose tests as directed. |
|
b. |
The patient occasionally
forgets to take the daily prescribed medication. |
|
c. |
The patient states that
dietary changes have not made any difference at all. |
|
d. |
The patient 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 believes that dietary changes do not affect symptoms.
The other responses do not indicate that the ineffective health maintenance is
caused by lack of motivation.
DIF: Cognitive Level: Apply
(application)
REF: 48
TOP: Nursing Process:
Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
10. A
patient with diabetic neuropathy 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. Demonstrating technique for trimming toenails and providing
instructions on foot care are actions that the nurse will take rather than
behaviors that indicate that patient learning has occurred. A learning goal
that states that the patient will understand the rationale for proper foot care
is too vague and nonspecific to measure whether learning has occurred.
DIF: Cognitive Level: Apply
(application)
REF: 54
TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
11. A
patient needs to learn how to instill eye drops. Which teaching strategy, if
implemented by the nurse, would be most effective?
|
a. |
Peer teaching |
|
b. |
Lecture-discussion |
|
c. |
Printed instructions |
|
d. |
Demonstration and return
demonstration |
ANS: D
Demonstration with return demonstration (show back) is best used
to teach a patient how to learn to perform a skill. Lecture-discussion, peer
teaching, and printed materials are more useful for other learning needs.
DIF: Cognitive Level: Understand
(comprehension)
REF: 56
TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
12. The
nurse and the patient who is diagnosed with hypertension develop 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. |
Have the patient list
substitutes for favorite foods that are high in sodium. |
|
b. |
Check the sodium content of
the patient’s menu choices over the next 3 days. |
|
c. |
Ask the patient to identify
which foods on the hospital menus are high in sodium. |
|
d. |
Compare the patient’s
sodium intake before and after the teaching was implemented. |
ANS: B
All of the answers address the patient’s sodium intake, but the
desired patient behaviors in the learning objective are most clearly addressed
by evaluating the sodium content of the patient’s menu choices.
DIF: Cognitive Level: Apply
(application)
REF: 57
TOP: Nursing Process:
Evaluation
MSC: NCLEX: Health Promotion and Maintenance
13. The
nurse prepares written handouts to be used as part of the standardized teaching
plan for patients who have been recently diagnosed with diabetes. What
statement would be most appropriate
to include in the handouts?
|
a. |
Eating the right foods can
help in keeping blood glucose at a near-normal level. |
|
b. |
Polyphagia, polydipsia, and
polyuria are common symptoms of diabetes mellitus. |
|
c. |
Some patients with diabetes
control blood glucose with oral medications, injections, or dietary
interventions. |
|
d. |
Diabetes mellitus is
characterized by chronic hyperglycemia and the associated symptoms than can
lead to long-term complications. |
ANS: A
The reading level for patient teaching materials should be at
the fifth grade level. The other responses have words with three or more
syllables, use many medical terms, or are too long.
DIF: Cognitive Level: Apply
(application)
REF: 52
TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
14. The
hospital nurse implements a teaching plan to assist an older patient who lives
alone to independently accomplish daily activities. How would the nurse best evaluate
the patient’s long-term response to the teaching?
|
a. |
Make a referral to the home
health nursing agency for home visits. |
|
b. |
Have the patient
demonstrate the learned skills at the end of the teaching session. |
|
c. |
Arrange a physical therapy
visit before the patient is discharged from the hospital. |
|
d. |
Check the patient’s ability
to bathe and get dressed without any assistance the next day. |
ANS: A
A home health referral would allow for the assessment of the
patient’s long-term response after discharge. The other actions allow
evaluation of the patient’s short-term response to teaching.
DIF: Cognitive Level: Apply
(application)
REF: 57
TOP: Nursing Process:
Evaluation
MSC: NCLEX: Health Promotion and Maintenance
15. A
patient who smokes a pack of cigarettes per day 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 or she is not
considering smoking cessation. Ineffective health maintenance is defined as the
inability to identify, manage, or seek out help to maintain health.
DIF: Cognitive Level: Apply
(application)
REF: 47
TOP: Nursing Process:
Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
16. An
older Asian patient, who is seen at the health clinic, is diagnosed with
protein malnutrition. What priority action
should the nurse include in the teaching plan?
|
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. |
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: Apply
(application)
REF: 49
OBJ: Special Questions:
Prioritization TOP: Nursing Process:
Planning
MSC: NCLEX: Health Promotion and Maintenance
17. A
middle-aged patient who has diabetes tells the nurse, “I want to know how to
give my own insulin so I don’t have to bother my wife all the time.” What is
the priority action
of the nurse?
|
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: Apply
(application)
REF: 47
OBJ: Special Questions:
Prioritization TOP: Nursing Process:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
18. The
nurse plans to teach a patient and the caregiver how to manage high blood
pressure (BP). Which action should the nurse take first?
|
a. |
Give written information
about hypertension to the patient and caregiver. |
|
b. |
Have the dietitian meet
with the patient and caregiver to discuss a low-sodium diet. |
|
c. |
Teach the caregiver how to
take the patient’s BP using a manual blood pressure cuff. |
|
d. |
Ask the patient and
caregiver to select information from a list of high BP teaching topics. |
ANS: D
Because 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 may also 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: Apply
(application)
REF: 47
OBJ: Special Questions:
Prioritization TOP: Nursing Process:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
19. A
postoperative patient and caregiver need discharge teaching. Which actions
included in the teaching plan can the nurse delegate to unlicensed assistive
personnel (UAP)?
|
a. |
Evaluate whether the
patient and caregiver understand the teaching. |
|
b. |
Show the caregiver how to
accurately check the patient’s temperature. |
|
c. |
Schedule the discharge
teaching session with the patient and caregiver. |
|
d. |
Give the patient a pamphlet
reinforcing teaching already done by the nurse. |
ANS: D
Providing a pamphlet to a patient to reinforce previously taught
material does not require nursing judgment and can safely be delegated to UAP.
Demonstration of how to take a temperature accurately, determining the best
time for teaching, and evaluation of the success of patient teaching all
require judgment and critical thinking and should be done by the registered
nurse.
DIF: Cognitive Level: Apply (application)
REF: 46
OBJ: Special Questions:
Delegation TOP: Nursing
Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
20. A
family caregiver tells the home health nurse, “I feel like I can never get away
to do anything for myself.” Which action is best for the
nurse to take?
|
a. |
Assist the caregiver in
finding respite services. |
|
b. |
Assure the caregiver that
the work is appreciated. |
|
c. |
Encourage the caregiver to
discuss feelings openly with the nurse. |
|
d. |
Tell the caregiver that
family members provide excellent patient care. |
ANS: A
Respite services allow family caregivers to have time away from
their caregiving responsibilities. The other actions may also be helpful, but
the caregiver’s statement clearly indicates the need for some time away.
DIF: Cognitive Level: Apply
(application)
REF: 49
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. The
nurse plans to provide instructions about diabetes to a patient who has a low
literacy level. Which teaching strategies should the nurse use (select all that apply)?
|
a. |
Discourage use of the
Internet as a source of health information. |
|
b. |
Avoid asking the patient
about reading abilities and level of education. |
|
c. |
Provide illustrations and
photographs showing various types of insulin. |
|
d. |
Schedule one-to-one
teaching sessions to practice insulin administration. |
|
e. |
Obtain CDs and DVDs that
illustrate how to perform blood glucose testing. |
ANS: C, D, E
For patients with low literacy, visual and hands-on learning
techniques are most appropriate. The nurse will need to obtain as much
information as possible about the patient’s reading level in order to provide
appropriate learning materials. The nurse should guide the patient to Internet
sites established by reputable heath care organizations such as the American
Diabetes Association.
DIF: Cognitive Level: Apply
(application)
REF: 52
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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