Nokea
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.
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You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response?
- A. This history helps us determine what your needs may be for nursing care.
- B. You are right; this may seem redundant and Im sure that its frustrating for you.
- C. I want to make sure your doctor has covered everything thats important for your treatment.
- D. I am a member of your health care team and we want to make sure that nothing falls through the cracks.
Correct Answer: A
Rationale: Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patients care plan. The nurse should address the patients concerns directly and avoid casting doubt on the thoroughness of the physician.
An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question?
- A. Tell me about your medications: How do you usually get them each day?
- B. Tell me about where you live: Do you feel your needs are being met, and do you feel safe?
- C. Your wheelchair would seem to limit your ability to move around. How do you deal with that?
- D. What limitations are you dealing with related to your health and being in a wheelchair?
Correct Answer: B
Rationale: The question, Tell me about where you live: Do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. An explicit focus on limitations may be counterproductive.
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.
A 51-year-old woman's recent complaints about fatigue are thought to be attributable to iron deficiency anemia. The patient's subsequent diagnostic testing includes quantification of her transferrin blood levels. This biochemical assessment would be performed by assessing which of the blood following?
- A. The patient's urine
- B. The patient's serum
- C. The patient's cerebrospinal fluid
- D. The patient's synovial fluid
Correct Answer: B
Rationale: Biochemical assessments are made from studies of serum (albumin, transferrin, ferritin, retinol, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). Transferrin is found in serum, not urine, CSF, or synovial fluid.
You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?
- A. Is anyone physically hurting you?
- B. Tell me about your relationships.
- C. Do you want to see a social worker?
- D. Is there something you want to tell me?
Correct Answer: A
Rationale: Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you? The other options are incorrect because they are not the best way to illicit information about possible abuse in a direct and appropriate manner.