Nokea
During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?
- A. Intestines
- B. Gall bladder
- C. Thyroid gland
- D. Pancreas
Correct Answer: C
Rationale: Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.
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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.
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.
The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?
- A. Have a family member provide the data.
- B. Obtain the data from the old chart and physicians assessment.
- C. Obtain the data only from the patient, prioritizing aspects that the patient understands.
- D. Collect all possible data from the patient and have the family supplement missing details.
Correct Answer: D
Rationale: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.
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.
A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns?
- A. Its been found that using computers improves our patients care and reduces their health care costs.
- B. We have found that it is easier to keep track of our patients information this way rather than with pen and paper.
- C. Youll find that all the hospitals are doing this now, and that writing information with a pen is rare.
- D. The government is telling us we have to do this, even though most people, like yourselves, are opposed to it.
Correct Answer: A
Rationale: Electronic health records are thought to improve the quality of care, reduce medical errors, and help reduce health care costs; therefore, their implementation is moving forward on a global scale. Electronic documentation is not always easier and most people are not opposed to it. Stating that all hospitals do this does not directly address their reluctance or state the benefits. The use of technology in health care settings is not specifically mandated by legislation.