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During a health assessment of an older adult with multiple chronic health problems, the nurse practitioner is utilizing multiple assessment techniques, including percussion. What is the essential principle component of percussion?
- A. To assess the sound created by the body
- B. To strike the abdominal wall with a soft object
- C. To create sound over dead spaces in the body
- D. To create vibration in a body wall
Correct Answer: D
Rationale: The principle of percussion is to set the vibration in the chest wall or abdominal wall into vibration by striking it with a firm object. Percussion is not limited to dead spaces or the abdomen. The body does not create the sounds resulting from percussion; sound is referred from striking the surface of the body.
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You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient?
- A. A) The U.S. Department of Agriculture's MyPlate
- B. B) Evidence-based resources on nutritional assessment
- C. C) Culturally sensitive materials, such as the Mediterranean Pyramid
- D. D) A Greek cookbook that contains academic references
Correct Answer: C
Rationale: Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. MyPlate is not explicitly culturally sensitive. Nursing resource books do not usually have culturally sensitive dietary specific material. A Greek cookbook would not be an appropriate clinical resource.
You are admitting an elderly woman who is accompanied by her husband. The husband wants to know where the information you are obtaining is going to be kept and you follow up by describing the system of electronic health records. The husband states, I sure am not comfortable with that. It is too easy for someone to break into computer records these days. What is your best response?
- A. The Institute of Medicine has called for the implementation of the computerized health record so all hospitals are doing it.
- B. Weve been doing this for several years with good success, so I can assure you that our records are very safe.
- C. This hospital is as concerned as you are about keeping our patients records private. So we take special precautions to make sure no one can break into our patients medical records.
- D. Your wifes records will be safe, because only people who work in the hospital have the credentials to access them.
Correct Answer: C
Rationale: Nurses must be sensitive to the needs of the older adults and others who may not be comfortable with computer technology. Special precautions are indeed taken. Not every hospital employee has access and referencing the IOM may not provide reassurance.
A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years?
- A. Lifelong eating habits are acquired.
- B. Peer pressure influences growth rate.
- C. BMI is determined.
- D. Culture begins begin to influence diet.
Correct Answer: A
Rationale: Adolescence is a time period of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, nutrition analysis, and intervention are critical. Peer pressure does not influence growth rate. Cultural influences tend to become less important during the teen years; they do not emerge for the first time at this age. BMI can be assessed at any age.
You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. Your patient wants to know why the hospital needs all this information about the way he eats, asking you, Are you asking me all these questions because I am Middle Eastern? What is your best response to this patient?
- A. We always try to abide by foreign-born patients dietary preferences in order to make them comfortable.
- B. We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these.
- C. We would not want to feed you anything you only eat on certain holidays.
- D. We know that patients who grew up in other countries often have unusual diets, and we want to accommodate this.
Correct Answer: B
Rationale: Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. A specific focus on foods eaten only on holidays is too narrow and does not convey the overall intent of the dietary interview. Dietary planning addresses all patients' needs, not only those who are foreign-born. It is inappropriate to characterize a patient's diet as unusual.
A patient has a newly diagnosed heart murmur. During the nurses subsequent health education, he asks if he can listen to it. What would be the nurses best response?
- A. Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur.
- B. Listening is called palpation, and I would be glad to help you to palpate your murmur.
- C. Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction.
- D. If you would like to listen to your murmur, Id be glad to help you and to show you how to use a stethoscope.
Correct Answer: D
Rationale: Listening with a stethoscope is auscultation and it is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs, whereas the bell is used to assess low-frequency sounds such as diastolic heart murmurs. It is also important to provide education whenever possible and actively include the patient in the plan of care. Teaching an interested patient how to listen to a murmur should be encouraged. Many heart murmurs are benign and do not require surgery.