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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.
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You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type 2 diabetes. Which question would best provide you with information about the role of food in the patients cultural practices and identify how the patients food preferences could be related to his problem?
- A. Do you feel any of your cultural practices have a negative impact on your disease process?
- B. What types of foods are served as a part of your cultural practices, and how are they prepared?
- C. As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care?
- D. Tell me about foods that are important in your culture and how you feel they influence your diabetes.
Correct Answer: D
Rationale: The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. Food plays a significant role in both cultural practices and type 2 diabetes. By asking the question, Tell me about the foods that are important in your culture and how you feel they influence your diabetes, the nurse demonstrates a cultural awareness to the client and allows an open-ended discussion of the disease process and its relationship to cultural practice. An overemphasis on negatives can inhibit assessment and communication. Assessing the types and preparation of foods specific to cultural practices without relating it to diabetes is inadequate. The question, As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care? focuses on care and fails to address the significance of food in cultural practice or diabetes.
A home care nurse is teaching meal-planning to a patients son who is caring for his mother during her recovery from hip replacement surgery. Which of the following meals indicates that the son understands the concept of nutrition, based on the U.S. Department of Agricultures MyPlate?
- A. Cheeseburger, carrot sticks, and mushroom soup with whole wheat crackers
- B. Spaghetti and meat sauce with garlic bread and a salad
- C. Chicken and pepper stir fry on a bed of rice
- D. Ham sandwich with tomato on rye bread with peaches and yogurt
Correct Answer: D
Rationale: This menu has a choice from each of the food groups identified in MyPlate: grains, vegetables, fruits, dairy, and protein. The other selections are incomplete choices.
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.
An older adult's unexplained weight loss of about 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurse's rationale for prioritizing biochemical assessment when appraising a person's nutritional status?
- A. It identifies abnormalities in the chemical structure of nutrients.
- B. It predicts abnormal utilization of nutrients.
- C. It reflects the tissue level of a given nutrient.
- D. It predicts metabolic abnormalities in nutritional intake.
Correct Answer: C
Rationale: Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. It does not focus on abnormalities in the chemical structure of nutrients. Biochemical assessment is not predictive.
In your role as a school nurse, you are working with a female high school junior whose BMI is 31 . When planning this girls care, you should identify what goal?
- A. Continuation of current diet and activity level
- B. Increase in exercise and reduction in calorie intake
- C. Possible referral to an eating disorder clinic
- D. Increase in daily calorie intake
Correct Answer: B
Rationale: A BMI of 31 is considered clinically obese; dietary and exercise modifications would be indicated. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29.9 are considered overweight; those with a BMI of 30 or greater are considered to be obese.