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A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?
- A. The patient does not understand the principles of nutrition.
- B. This is an aspect of the patients religious practice.
- C. This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition.
- D. This is an example of the patients coping strategies.
Correct Answer: B
Rationale: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patients religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition.
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You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?
- A. The patient may be at risk for developing diabetes.
- B. The patient may need teaching on the effects of diabetes.
- C. The patient may need to attend a support group for individuals with diabetes.
- D. The patient may benefit from a dietary regimen that tracks glucose intake.
Correct Answer: A
Rationale: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.
You are performing the admission assessment of a patient who is being admitted to the postsurgical unit following knee arthroplasty. The patient states, Youve got more information on me now than my own family has. How do you manage to keep it all private? What is your best response to this patients concern?
- A. Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it.
- B. Your information is available only to people who currently work in patient care here in the hospital.
- C. Your information is kept electronically on a secure server and anyone who gets permission from you can see it.
- D. Your information is only available to professionals who care for you and representatives of your insurance company.
Correct Answer: A
Rationale: This written record of the patients history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. Only those caring for the patient have access to the health record. Insurance companies have the right to know the patients coded diagnoses so that bills may be paid; they are not privy to the health record.
You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?
- A. Is anyone physically hurting you?
- B. Tell me about your relationships.
- C. Do you want to see a social worker?
- D. Is there something you want to tell me?
Correct Answer: A
Rationale: Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you? The other options are incorrect because they are not the best way to illicit information about possible abuse in a direct and appropriate manner.
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 who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate?
- A. The patient is a normal weight.
- B. The patient is extremely obese.
- C. The patient is overweight.
- D. The patient is mildly obese.
Correct Answer: B
Rationale: Individuals who have a BMI between 25 and 29.9 are considered overweight. Obesity is defined as a BMI of greater than 30 (WHO, 2011). A BMI of 45 would indicate extreme obesity.