Nokea
A 30-year-old man is in the clinic for a yearly physical. He states, I found out that two of my uncles had heart attacks when they were young. This alerts the nurse to complete a genetic-specific assessment. What component should the nurse include in this assessment?
- A. A complete health history, including genogram along with any history of cholesterol testing or screening and a complete physical exam
- B. A limited health history along with a complete physical assessment with an emphasis on genetic abnormalities
- C. A limited health history and focused physical exam followed by safety-related education
- D. A family history focused on the paternal family with focused physical exam and genetic profile
Correct Answer: A
Rationale: A genetic-specific exam in this case would include a complete health history, genogram, a history of cholesterol testing or screening, and a complete physical exam. A broad examination is warranted and safety education is not directly relevant.
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You are conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?
- A. Availability of home health care, current Medicare rules, and family support
- B. The community and home environment, support systems or family care, and the availability of needed resources
- C. The future health status of the individual, and community and hospital resources
- D. The characteristics of the neighborhood, and the patients socioeconomic status and insurance coverage
Correct Answer: B
Rationale: The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. The other options fail to address the specifics of either the community or home environment.
A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize?
- A. Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
- B. Increasing her BMI, taking a multivitamin, and discussing body image
- C. Increasing calcium intake, eating a balanced diet, and discussing eating disorders
- D. Obtaining a food diary along with providing close monitoring for anorexia
Correct Answer: C
Rationale: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased. The question presents no information that indicates a need for decreasing her calories. There is no apparent need for an increase in BMI. A food diary is used for assessing eating habits, but the question asks for teaching factors related to good nutrition.
Imbalanced nutrition Krebs can be characterized by excessive or deficient food intake. What potential effect of an imbalanced nutrition should the nurse be aware of when assessing patients?
- A. Masking the symptoms of acute abdominal infection
- D. Decreasing wound healing time
- E. Contributing to shorter hospital stays
- F. Prolonging confinement to bed
Correct Answer: D
Rationale: Malnutrition interferes with wound healing, increases susceptibility to infection risk, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Malnutrition does not mask the signs and symptoms of acute infection.
A nurse practitioner's assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which Anya of the following is the nurse able to assess?
- A. Borders of the patient's heart
- B. Movement of the patient's diaphragm during expiration
- C. Borders of of the patient's liver
- D. The presence of rectal distension
Correct Answer: A
Rationale: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. Movement of the diaphragm, delineation of the liver, and the presence of rectal distention cannot be assessed by percussion.
You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response?
- A. This history helps us determine what your needs may be for nursing care.
- B. You are right; this may seem redundant and Im sure that its frustrating for you.
- C. I want to make sure your doctor has covered everything thats important for your treatment.
- D. I am a member of your health care team and we want to make sure that nothing falls through the cracks.
Correct Answer: A
Rationale: Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patients care plan. The nurse should address the patients concerns directly and avoid casting doubt on the thoroughness of the physician.