Nurs 251 Health Assessment
Which assessment takes priority in an emergency assessment of a patient? - ANS A) Pulse
*B) Airway/breathing*
C) Blood pressure
D) Skin color
Asking a colleague to recheck a blood pressure to see if he/she gets a similar reading as you, is
an example of which of the following? - ANS *A) Validation*
B) Interpretation
C) Reflection
D) Documentation
The nurse is interviewing for the first time, a Hispanic patient with limited English skills. The
nurse observes that the patient is reluctant to reveal personal information and that he believes
in a hot-cold syndrome of disease causation. What should the nurse do in this situation? - ANS
A) Remain in a standing position during the interview
B) Use slang terms to identify certain body parts
C) Request a family member interpret for the patient
*D) Indicate acceptance of the patient's cultural differences*
Planning - ANS Developing a plan of nursing care and outcome criteria
Assessment - ANS Collection of subjective and objective data
Nursing diagnosis - ANS Clinical judgement about individual, family or community responses to
actual or potential health problems and life processes
Evaluation - ANS Assessing whether outcome criteria have been met and revising the plan of
care if necessary
Implementation - ANS Carrying out the plan
Because the nurse realizes that spirituality varies, how will the information gained during a
spirituality assessment assist the nurse? - ANS *A) By individualizing interventions to meet
specific needs*
B) By providing an overview of widely held beliefs from the major religions
C) In diagnosing the patient with spiritual distress
D) In teaching the patient strict adherence to rituals and practices to improve outcomes
, Which of the following groups is very time conscious and maintains eye contact while speaking
to another person? - ANS A) African-American
*B) Euro-American*
C) Asian
D) Hispanic
Physical assessment provides which type of data? - ANS A) Symptoms
B) Current medical history
C) Subjective
*D) Objective*
What is the policy called that requires using protective measures to minimize the exposure to
potentially infectious body fluids? - ANS A) Common sense
B) Handwashing
*C) Standard precautions*
D) Body substance isolation
A simplified, generally inflexible conception of the members of a group or subgroup is the
definition of which of the following terms? - ANS A) Cultural sensitivity
B) Ethnocentrism
*C) Stereotype*
D) Ethnicity
What is the term (when defined broadly) that describes a body of shared traits, art, or ideas? -
ANS *A) Culture*
B) Rituals
C) Customs
D) Values
George is a 50 year old male that has never sought preventative care prior to today. He arrives
at a primary care clinic for the first time. The Registered Nurse (RN) will perform what type of
assessment upon meeting George? - ANS A) Focused/Problem
*B) Initial/comprehensive*
C) Ongoing/partial
D) Emergency
Visceral - ANS Diffuse, hard to locate, originates from organs
Deep somatic - ANS Diffuse, originates in muscles, joints or parietal surfaces
Radiating - ANS Pain which moves outward from a central location
Referred - ANS Pain in an area removed from the tissue causing the pain
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