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GNUR 238 Exam 1 Questions And Complete Answers
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GNUR 238 Exam 1 Questions AndComplete Answers
A 52 year old male patient is admitted to the hospital with a new diagnosis of rectal
cancer. The nurse conducts which type of assessment on his admission?
A. comprehensive assessment
B. problem-based assessment
C. episodic assessment
D. screening assessment for colorectal cancer - Answer A. comprehensive assessment:
detailed history and physical examination performed at the onset of care in a primary
care setting, admission to a hospital, or long term care facility. Encompasses health
problems experienced by the patient; health promotion, disease prevention, and
assessment for problems associated with known risk factors; or assessment for age and
gender specific health problems
The formation of a plan of care is initiated with?
A. analysis of data
B. collection of data
C. clustering of data
D. identification of nursing diagnosis - Answer B. collection of data
During an interview the nurse learns that a patient has a 5 year history of hypertension.
Which health promotion intervention is most appropriate at this time?
A. teaching the patient how to relieve stress to prevent hypertension
B. monitoring and minimizing the progression of hypertension
C. establishing a screening schedule for detection of hypertension.
D. advising the patient on the benefits of exercise to lower blood pressure. - Answer B.
monitoring and minimizing the progression of hypertension
A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What
type of data does this information represent?
A. subjective data
B. objective data
C. subjective and objective data
,D. secondary source data - Answer C. subjective and objective data:
Signs are the objective data observed, felt, heard, or measured. Symptoms are
subjective data perceived and reported by the patient.
Which process does the clustering of data facilitate?
A. analyzing data
B. collecting data
C. implementing data
D. evaluating nursing care - Answer A. analyzing data
The nurse is interviewing an adult Navajo woman. Which statement demonstrates
cultural sensitivity and acceptance of the patient?
A. "how often do you visit the medicine man for your health care?"
B. "tell me about your health care beliefs and practices."
C. "many Navajo people are afraid of hospitals. Are you afraid?"
D. 'have you ever had a physical examination with a physician or nurse practitioner?" -
Answer B. "tell me about your health care beliefs and practices."
The nurse is conducting an interview with Jermey, a 17 year old accompanied by his
mother. Which statement by the nurse is an age appropriate adjustment when
conducting a health history on an adolescent?
A. Jermey, do you have a girlfriend, and if so are you sexually active?
B. Mrs. Williams, is your son sexually active yet?
C. Jermey, how do you incorporate safe sex practices into your daily life?
D. Mrs. Williams, would you mind waiting outside for a few minutes while I discuss a few
things with Jermey? - Answer D. Mrs. Williams, would you mind waiting outside for a few
minutes while I discuss a few things with Jermey?
During an interview an elderly patient tells the nurse that she has periodic problems
keeping her balance. The nurse asks her what she is doing when the episodes occur.
Which area of the symptom analysis is the nurse pursuing with this question?
A. severity
B. frequency
C. aggravation factors
D. location - Answer C. aggravation factors
,Which communication technique conveys genuine interest in what the patient has to
say?
A. active listening
B. sitting close to the patient
C. maintaining professional dress conduct
D. holding the patient's hand during the interview - Answer A. active listening: involves
listening with a purpose to spoken words as well as noticing nonverbal behaviors. Do
not predict how the patient will respond or form the next question while the patient is
talking.
A 62 year old patient tells the nurse that he is in excellent health and does not take any
medication. What is the most appropriate response by the nurse to follow up on the
patient's statement?
A. do you avoid taking drugs because of bad experiences
B. which medications have you taken in the past
C. that is hard to believe. Most med your age take medications.
D. do you use over the counter medications or herbal preparations? - Answer D. do you
use over the counter medications or herbal preparations?
The nurse obtains vital signs on a 42 year old man having his annual physical
examination. He has no medical conditions and states that his health is excellent. His
blood pressure appears 62/40 using an automated blood pressure device. Which action
by the nurse is most appropiate?
A. obtain a different cuff and take the blood pressure again.
B. take the blood pressure again using the auscultation method.
C. place the patient in a supine position and take the pressure on the leg.
D. record the blood pressure and continue with the examination. - Answer B. take the
blood pressure again using the auscultation method.
Which set of vital signs should the nurse recognize as out of the expected range?
A. 42 year old man: BP 114/82; pulse 74; respiration 16; temperature 36.8 C
B. 11 year old girl: pulse 88; respiration 22; temperature 36.7 C
C. 3 year old boy: pulse 130; respiration 44; temperature 36.7 C
D. 1 month old girl: pulse 120; respiration 42; temperature 36.7 C - Answer C. 3 year old
boy: pulse 130; respiration 44; temperature 36.7 C
, respirations should be 24-40.
The nurse records the following general inspection findings on a patient: "41 year old
Hispanic male in no distress; very thin, skin tone slightly jaundiced, disheveled
appearance, and appears older than stated. Patient with flat affect and makes minimal
eye contact." What addition information should be added to this general inspection?
A. body movement
B. family history
C. estimated size of his liver
D. palpation of pulse - Answer A. body movement: general inspection begins the
moment you meet the patient. Involves observation of his or her physical appearance,
hygiene, body structure, body movement, emotional and mental status, and behavior.
A patient is brought to the emergency department with a severe respiratory distress.
Which method of temperature measurement would be most appropriate?
A. oral temperature with electric thermometer
B. axially with an electric thermometer
C. temporal artery
D. rectal temperature. - Answer C. temporal artery
A 62 year old patient tells the nurse that he has recently had frequent fainting spells.
After palpating the radial pulse, 13 pulsations are counted in 15 seconds. The nurse
determines a pulse rate of 52, with a regularly irregular rhythm. What is the most
appropriate action for the nurse at this time?
A. reassesses the pulse rate after he walks around the room for several minutes.
B. reassesses the pulse rate for 15 seconds using the carotid artery.
C. take an apical pulse for 5 full minutes, counting the number of skipped beats.
D. palpate the pulse for a full minute and note whether there is a pattern to the
irregularity. - Answer D. palpate the pulse for a full minute and note whether there is a
pattern to the irregularity.
The nurse is caring for a patient with a femur fracture. An external fixator is used to
maintain alignment of the femur. The nurse palpates the top of the foot to make which
determination?
A. amount of drainage from the wound
B. adequacy of blood perfusion to the foot
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