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which factors within the patients history is prob
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The Concept of Assessment Pearson
Practice Questions
The nurse is acquiring a records from the parents of a 10-month-vintage toddler. The dad
and mom are worried that, compared with other toddlers, their infant appears very small.
Which resource ought to the nurse use to offer help when decoding findings associated with
the little one's top and weight?
A) size of both mother and father
b) evaluation of present day weight and period to beginning weigh and length
c) amount of weight gain given that ultimate visit
d) standardized boom charts
d (standardized boom charts; When deciphering findings, the nurse should be able to get
right of entry to dependable resources that suggest degrees and norms of expectations. In
this example, a standardized boom chart might help to decide the toddler's reputation. Size
of both parents, weight gain given that remaining visit, and evaluating current weight with
beginning weight will now not provide standardized norms for comparison.)
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An eighty two-year-antique patient is introduced to the healthcare issuer's office due to
recent lack of ability to finish sports of each day dwelling (ADLs). Until recently, the daughter
reviews that the affected person were able to live independently. The patient lives on my own
due to the fact their partner died one month previous. The affected person is alert and
orientated however appears a bit matted and does not study the nurse throughout the
evaluation process.
Which factors within the patient's history is probably most vital to deciphering this affected
person's latest lack of ability to complete ADLs?
A) psychologic and emotional factors
b) developmental factors (age)
c) environmental factors
d) cognitive factors
,a (psychologic and emotional elements; Psychologic and emotional elements together with
grieving can restrict a patient's capability to carry out ADLs. In this situation, the latest dying
of the affected person's partner may be contributing to their inability to do so. While age and
cognitive and environmental factors can contribute to adjustments, there is no evidence in
this situation to suggest that these are the elements.)
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While auscultating the lung sounds of a patient with continual obstructive pulmonary disease
(COPD), the nurse notes scattered high-pitched wheezes.
Which element of lung sounds is described by this evaluation?
A) the depth of the sounds
b) the first-class of the sounds
c) the frequency of vibrations
d) the period of the sounds
c (the frequency of vibrations; high pitched wheezes describes the pitch or the frequency of
vibrations stated all through the auscultation. Depth, length, and great also can be
mentioned for the duration of auscultation however aren't pondered in the nurse's modern
evaluation.)
During an assessment on the network-primarily based clinic for a affected person who these
days immigrated to the US, the nurse notes that the affected person does no longer observe
the nurse when questions are being requested.
When deciphering this locating, which issue ought to the nurse take into consideration?
A) worry of being deported can be impacting the affected person's behavior
, b) cultural norms might also play a role on this conduct
c) differences in sex may be a element main to this behavior
d) mental elements along with anxiety may be inflicting this conduct
b (cultural norms might also play a position on this conduct; affected person assessment
information need to be interpreted when it comes to cultural norms. As an instance, some
cultures do no longer recollect lack of eye touch for the duration of an interaction as
consultant of depression or incapability to engage. There's no statistics to signify fear of
deportation or tension. Intercourse variations may additionally at times make contributions to
such behavior however no facts on this state of affairs supports the want to do not forget this
issue.)
The own family of a nursing home resident tells the nurse that they think their family member
is experiencing cognitive modifications.
During the assessment, which extra useful resource must the nurse use to help interpret
findings?
A) stanford-binet iq take a look at
b) geriatric melancholy scale
c) nursing home workforce observations
d) mini-mental reputation exam (mmse)
d (mini-mental status exam; to interpret the family reports, the nurse must conduct a
Mini-Mental Status Exam (MMSE), which could help to objectively detect cognitive decline.
Nursing body of workers observations would be every other supply of subjective statistics,
which can be useful, but an objective dimension might be best. The Geriatric Depression
Scale measures despair, no longer cognitive impairment. The Stanford-Binet IQ take a look
at measures intelligence, no longer cognitive decline.
When is it appropriate to conduct a trouble-targeted or system-precise assessment?
A) when assessing a affected person in mental or bodily crisis
b) when it's far part of an ongoing procedure incorporated with nursing care
c) while evaluating findings several months after preliminary patient evaluation
d) on the patient's first appointment to establish criteria for later contrast
b ( when it is part of an ongoing technique incorporated with nursing care; Problem-focused
or machine-particular assessment is finished as an ongoing procedure that is included with
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