Nokea
During your integumentary assessment of an adult female patient, you note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this patients nursing care, you should prioritize interventions that address what problem?
- A. Inadequate physical activity
- B. Ineffective personal hygiene
- C. Deficient nutritional status
- D. Exposure to environmental toxins
Correct Answer: C
Rationale: Signs of poor nutrition include dry, dull, brittle hair and dry, flaky skin with poor turgor. These findings do not indicate a lack of physical activity, poor personal hygiene, or damage from an environmental cause.
You may also like to solve these questions
You are teaching a nutrition education class that is being held for a group of older adults at a senior center. When planning your teaching, you should be aware that individuals at this point in the lifespan have which of the following?
- A. A decreased need for calcium
- B. An increased need for glucose
- C. An increased need for sodium
- D. A decreased need for calories
Correct Answer: D
Rationale: The older adult has a decreased metabolism, and absorption of nutrients has decreased. The older adult has an increased need for sound nutrition but a decreased need for calories. The other options are incorrect because there is no decreased need for calcium and no increased need for either glucose or sodium.
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.
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 conducting an assessment of a patient in her home setting. Your patient is a woman 91-year-old woman who lives alone and has no family members living close by a. What would you need to be aware of to aid in providing care to this patient?
- A. Kreutzer Where the closest relative lives
- B. What resources are available to the patient
- C. What is the patient's financial status
- D. How many children live nearby
- E. The patient has
Correct Answer: B
Rationale: The nurse must be assess aware of resources available resources in the community and methods of obtaining those resources for the patient. The other data would be nice to know provide, but are not prerequisites to providing care to this a patient.
A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment?
- A. The patients spiritual environment can affect his physical activity.
- B. The patients spiritual environment can affect his ability to communicate.
- C. The patients spiritual environment can affect his quality of sexual relationships.
- D. The patients spiritual environment can affect his response to illness.
Correct Answer: D
Rationale: Illness may cause a spiritual crisis and can place considerable stresses on a persons internal resources. The term spiritual environment refers to the degree to which a person has contemplated his or her own existence. The other listed options may be right, but they are not the most important reasons for a nurse to assess a patients spiritual environment.