advanced health assessment test bank

advanced health assessment test bank Related

Review advanced health assessment test bank related questions and content

The nurse is planning to assess new memory with a patient. The best way to do this would be to:

  • A. Administer the FACT test.
  • B. Ask him to describe his first job to you.
  • C. Give him the Four Unrelated Words Test.
  • D. Ask him to describe the last TV show he watched before coming to the clinic.
Correct Answer: C

Rationale: The correct answer is C: Give him the Four Unrelated Words Test. This is the best way to assess new memory because it is a standardized test specifically designed to evaluate a patient's ability to form new memories. The test involves presenting the patient with four unrelated words and then asking them to recall those words after a delay. This test is reliable, valid, and widely used in clinical settings to assess new memory formation.

Other choices are incorrect because:

A: Administering the FACT test is not the best way to assess new memory as it is not specifically designed for this purpose.

B: Asking the patient to describe his first job does not directly evaluate new memory formation and may not provide a standardized assessment.

D: Asking the patient to describe the last TV show he watched does not focus on new memory and is not a standardized way to assess memory function.

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The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs audibly. Which of the following statements does the nurse know is most accurate, considering the concept of communication?

Correct Answer: B

Rationale: The correct answer is B because the woman's nonverbal cues (looking nervously at her hands, sighing audibly) indicate potential anxiety or stress. The nurse should acknowledge these cues and explore her feelings further to provide appropriate support. Option A is incorrect as it does not address the woman's nonverbal cues. Option C is incorrect as it assumes the woman is not genuinely excited about the pregnancy. Option D is incorrect as it overlooks the woman's nonverbal cues and does not address her potential emotional needs.

A nurse is caring for a patient with acute pancreatitis. The nurse should monitor for which of the following signs of complications?

  • A. Decreased urine output and increased thirst.
  • B. Increased blood pressure and heart rate.
  • C. Hypotension and tachycardia.
  • D. Tachypnea and cyanosis.
Correct Answer: C

Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.

When providing culturally competent care, nurses must incorporate cultural assessment into their health assessment. Which statement is most appropriate to use when initiating a cultural beliefs assessment with a First Nations elder?

  • A. Are you of the Christian faith, or another faith?
  • B. Do you want to see a medicine man?
  • C. How often do you seek help from medical providers?
  • D. What cultural or spiritual beliefs are important to you?
Correct Answer: D

Rationale: The correct answer is D: "What cultural or spiritual beliefs are important to you?" This question allows the nurse to understand the elder's values and beliefs, guiding care. A: Assumes a specific faith. B: Stereotypes the elder. C: Focuses on frequency of medical visits, not beliefs.

Which of the following statements about nursing diagnoses is true? Nursing diagnoses:

  • A. evaluate the etiology of disease.
  • B. are a process based on medical diagnosis.
  • C. evaluate the response of the whole person to actual or potential health problems.
  • D. focus on the function and malfunction of a specific organ system in response to disease.
Correct Answer: C

Rationale: Rationale:
1. Nursing diagnoses evaluate the response of the whole person to health problems, not just specific organ systems.
2. They focus on the individual's physical, emotional, social, and spiritual well-being.
3. Nursing diagnoses are independent of medical diagnoses and consider the person holistically.
4. Option C aligns with the nursing process and the holistic approach of nursing care.

Summary:
Option A is incorrect as nursing diagnoses do not solely evaluate the etiology of disease. Option B is incorrect as nursing diagnoses are independent of medical diagnoses. Option D is incorrect as nursing diagnoses focus on the whole person, not just specific organ systems.

A nurse is teaching a patient with diabetes about insulin administration. Which of the following statements by the patient indicates proper understanding?

  • A. I will inject insulin into my arm to ensure faster absorption.
  • B. I will rotate injection sites to avoid tissue damage.
  • C. I should inject insulin only when my blood glucose is elevated.
  • D. I should inject insulin into the same spot every time to ensure consistency.
Correct Answer: B

Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.

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