Nokea
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.
You may also like to solve these questions
You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. Your patient wants to know why the hospital needs all this information about the way he eats, asking you, Are you asking me all these questions because I am Middle Eastern? What is your best response to this patient?
- A. We always try to abide by foreign-born patients dietary preferences in order to make them comfortable.
- B. We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these.
- C. We would not want to feed you anything you only eat on certain holidays.
- D. We know that patients who grew up in other countries often have unusual diets, and we want to accommodate this.
Correct Answer: B
Rationale: Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. A specific focus on foods eaten only on holidays is too narrow and does not convey the overall intent of the dietary interview. Dietary planning addresses all patients' needs, not only those who are foreign-born. It is inappropriate to characterize a patient's diet as unusual.
A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize?
- A. Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
- B. Increasing her BMI, taking a multivitamin, and discussing body image
- C. Increasing calcium intake, eating a balanced diet, and discussing eating disorders
- D. Obtaining a food diary along with providing close monitoring for anorexia
Correct Answer: C
Rationale: Adolescent girls are considered to be at high risk for nutritional disorders. Increasing calcium intake and promoting a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased. The question presents no information that indicates a need for decreasing her calories. There is no apparent need for an increase in BMI. A food diary is used for assessing eating habits, but the question asks for teaching factors related to good nutrition.
A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital?
- A. A physical assessment in the community consists of largely the same techniques as are used in the hospital.
- B. A physical assessment made in the community does not require Kreutzb the privacy that a physical assessment made in the hospital setting requires.
- D. A physical assessment made in a community requires that the patient be made more comfortable increase than would be necessary in the hospital setting.
- E. A physical assessment made in a community varies in technique from that conducted in the hospital setting by being less structured.
Correct Answer: A
Rationale: The physical assessment in the community assessment and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, provided and the person is made as well as possible comfortable as possible. The importance of comfort, privacy, and structure are similar in both settings.
A 30-year-old man is in the clinic for a yearly physical. He states, I found out that two of my uncles had heart attacks when they were young. This alerts the nurse to complete a genetic-specific assessment. What component should the nurse include in this assessment?
- A. A complete health history, including genogram along with any history of cholesterol testing or screening and a complete physical exam
- B. A limited health history along with a complete physical assessment with an emphasis on genetic abnormalities
- C. A limited health history and focused physical exam followed by safety-related education
- D. A family history focused on the paternal family with focused physical exam and genetic profile
Correct Answer: A
Rationale: A genetic-specific exam in this case would include a complete health history, genogram, a history of cholesterol testing or screening, and a complete physical exam. A broad examination is warranted and safety education is not directly relevant.
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?
- A. The patient does not understand the principles of nutrition.
- B. This is an aspect of the patients religious practice.
- C. This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition.
- D. This is an example of the patients coping strategies.
Correct Answer: B
Rationale: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patients religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition.