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Nursing Health Assessment Exam # 1 Questions With Complete Solutions
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Nursing Health Assessment Exam # 1 Questions With Complete Solutions
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Nursing Health Assessment Exam # 1 Questions WithComplete Solutions
"why" questions Correct Answer Places patients on the defense
24-hour recall Correct Answer consists of asking the patient
what they had to eat and drink within a 24-hour period
3-day food diary Correct Answer The diary shifts most of the
responsibility for data collection from the nurse to the patient. It
is best for the patient to write down the intake immediately after
eating. This record does not rely on memory, but the patient may
consciously alter the diet during recording. It is also time
consuming
4 Piaget stages Correct Answer -1(sensorimotor stage): birth to
2 yrs, coordination of sensory input and motor responses;
development of object performance
-2(preoperational period): 2 to 7 yrs, development of symbolic
thought marked by irreversibility, centration, and egocentrism
-3(concrete operational period): 7 to 11 yrs, mental operations
applied to concrete events; mastery of conservation, hierarchical
classification
-4(formal operational period): 11 to adulthood, mental
operations applied to abstract ideas; logical, systemic thinking
ABCDE Correct Answer The ABCD framework identifies the
three basic needs for sustaining life in order. The severity of
symptoms should also be considered when determining
priorities
,active listening Correct Answer the ability to focus on patients
and their perspectives. It requires that you constantly decode
messages, including thoughts, words, opinions, and emotions
admission assessment Correct Answer provides all future care
providers with Comprehensive information about the patient's
physical, psychological, functional, social, and spiritual abilities
airborne percaution Correct Answer -for patients known or
suspected to be infected with pathogens transmitted by the
airborne route
allergies Correct Answer Verify allergies with patients and
compare them with those stated in their medical records. When
asking about allergies, it is essential to note the type of response,
such as rash, throat swelling, difficulty breathing, or
anaphylactic shock
apnea Correct Answer absence of spontaneous respirations for
>10 secs
assessment Correct Answer complete and accurate health
assessment to promote health at the highest level
asystole Correct Answer is the absence of a pulse
auscultation Correct Answer -you will listen for sounds of
movement from organs and tissues. A stethoscope is used to
transmit normally unheard sounds
-includes BP, lungs, heart, and abdomen
,beginning Correct Answer Introduce yourself by name and
state the purpose of the interview. It is appropriate to ask the
patient how they would like to be addressed. A discussion of
some neutral areas, such as the weather, especially if you note
anxiety.
bell Correct Answer used with light skin contact to hear low-
frequency sounds; the diaphragm is used with firm skin contact
to hear high-frequency sounds.
biased questions Correct Answer is often an unintentional
nontherapeutic response. Biased questions carry judgment and
lead patients to respond in a way that they think will be
acceptable to you. Biased questions may also cause patients to
feel guilty or inferior about unhealthy behaviors
biots respirations Correct Answer an abnormal breathing
pattern that's characterized by irregular periods of apnea, or no
breathing, alternating with periods of regular, deep breathing
body system Correct Answer a logical tool for organizing data
when documenting and communicating findings. This method
promotes critical thinking and allows you to analyze findings as
you cluster similar data
bradycardia Correct Answer is a heart rate <60 beat/min
bradypnea Correct Answer persistent respiratory rate <8-12
breaths/min
, Carbohydrates Correct Answer provide the body's main source
of energy
cardiac immediate attention Correct Answer -SBP <90, DBP
>110
-HR <50 or >120 bpm
-new onset chest pain
caring Correct Answer encompasses your empathy for and
connection with the patient. It also includes the ability to
demonstrate emotional characteristics such as compassion,
sensitivity, and patient-centered care
changing the subject Correct Answer Avoiding the subject is
not therapeutic for the patient; you need to recognize that you
are using coping mechanisms to protect yourself from emotional
distress. One strategy is to seek support from others. An
alternate approach is to be honest with the patient about your
situation. If emotional control is too difficult, you may refer the
patient to another nurse
charting by exception Correct Answer uses predetermined
standards and norms to record only significant assessment data.
clearly identifying the standards and norms and educating all
users take time and significant commitment for the agency
cheyne-stokes respirations Correct Answer end-of life.
stop/come back
clarification Correct Answer is important when the patient's
word choice or ideas are unclear
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