Nokea
You are conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?
- A. Availability of home health care, current Medicare rules, and family support
- B. The community and home environment, support systems or family care, and the availability of needed resources
- C. The future health status of the individual, and community and hospital resources
- D. The characteristics of the neighborhood, and the patients socioeconomic status and insurance coverage
Correct Answer: B
Rationale: The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. The other options fail to address the specifics of either the community or home environment.
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A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age?
- A. Protein intake in this age group often falls below recommended levels.
- B. Total calorie intake is typically often insufficient at this age.
- C. Calcium intake is above the recommended levels.
- D. Folate intake is below the recommended levels in this age group.
Correct Answer: D
Rationale: Adolescent girls are at particular nutritional risk because iron, folate, folate and calcium intakes are below recommended levels, and they are a less physically active group compared to adolescent males. Protein and calorie intake is most often sufficient.
You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the patients neck?
- A. Inspection
- B. Auscultation
- C. Palpation
- D. Percussion
Correct Answer: C
Rationale: Palpation is a part of the assessment that allows the nurse to assess a body part through touch. Many structures of the body (superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum), although not visible, may be assessed through the techniques of light and deep palpation. The other options are incorrect because lymph nodes are not assessed through inspection, auscultation, or percussion.
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.
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.
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.