health assessment exam 2 test bank

health assessment exam 2 test bank Related

Review health assessment exam 2 test bank related questions and content

During an interview, a woman says, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?

  • A. It was a therapeutic response. By sharing something personal, the nurse gives hope to this woman.
  • B. It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation.
  • C. It was a therapeutic response. By providing information about the medications available, the nurse is giving reassurance to the woman.
  • D. It was a nontherapeutic response. The nurse's statement minimized the patient's anxiety and did not address her concerns.
Correct Answer: B

Rationale: The correct answer is B: It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation.

Rationale:
1. The nurse's response of dismissing the woman's fear and immediately shifting the focus to medication options invalidates the woman's feelings.
2. By sharing her own experience without acknowledging the woman's emotions, the nurse fails to provide genuine support.
3. The response lacks empathy and fails to address the woman's emotional needs, thus hindering effective communication.
4. This type of response may discourage the woman from expressing her concerns openly in the future, leading to potential emotional distress.

Summary of other choices:
A: Incorrect. Sharing personal experience alone does not make it therapeutic. In this context, it did not address the woman's emotional concerns effectively.
C: Incorrect. Providing information about medications, although helpful, does not address the woman's emotional distress and fears.
D: Incorrect. While the response did minimize the patient

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A nurse is caring for a patient who has undergone a colonoscopy. The nurse should prioritize monitoring for which of the following complications?

  • A. Hypotension.
  • B. Bleeding or perforation.
  • C. Constipation.
  • D. Pain at the insertion site.
Correct Answer: B

Rationale: The correct answer is B: Bleeding or perforation. After a colonoscopy, the patient is at risk for bleeding or perforation which are serious complications requiring immediate attention. Monitoring for signs such as abdominal pain, rectal bleeding, or signs of peritonitis is crucial. Choice A is not a priority unless the patient shows signs of shock. Choice C is a common post-procedure issue but not a priority complication. Choice D, pain at the insertion site, is expected and can be managed with analgesics.

A patient has been in the critical care unit for 10 days. He has just been moved to the medical"“surgical unit, and the admitting nurse is planning to perform a mental health examination. During the cognitive function tests, the nurse would expect that he:

  • A. Might display some disruption in thought content.
  • B. Might state, "I am so relieved to be out of critical care.'
  • C. Might be oriented to place and person but not be certain of the date.
  • D. Might show evidence of some clouding of consciousness.
Correct Answer: C

Rationale: The correct answer is C. After being in critical care for 10 days, it is expected that the patient may be disoriented to time but still be oriented to place and person. This is a common occurrence due to the stressful and disorienting environment of the critical care unit. The patient's cognition may be temporarily affected, leading to difficulty in remembering the date accurately. The patient's ability to recognize their surroundings and identify themselves and others should still be intact. Choices A, B, and D are incorrect because disruption in thought content, expressing relief, and clouding of consciousness are not typical cognitive function issues expected in this scenario.

In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:

  • A. last glaucoma examination.
  • B. frequency of breast self-examination.
  • C. date of her last electrocardiogram.
  • D. limitations related to her involvement in sports activities.
Correct Answer: D

Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.

A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of exacerbation?

  • A. Increased sputum production and shortness of breath.
  • B. Improved oxygen saturation.
  • C. Increased energy levels.
  • D. Decreased respiratory rate.
Correct Answer: A

Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications.

B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition.
C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations.
D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse would expect to find which of the following?

  • A. Anasarca.
  • B. Scleroderma.
  • C. Pedal erythema.
  • D. Clubbing of the nails.
Correct Answer: D

Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.

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