Exam (elaborations)
Fundamentals of Nursing - Chapter 30 correctly answered to pass
- Course
- Fundamentals Of Nursing Care
- Institution
- Hondros College School Of Nursing
Fundamentals of Nursing - Chapter 30 correctly answered to pass
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Fundamentals of Nursing - Chapter 30A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the
new graduate nurse begins to explain to the patient the purpose of completing a physical assessment.
Which of the following statements made by the new graduate nurse requires the preceptor to
intervene?
a. "I will use the information from my assessment to figure out if your antihypertensive medication is
working effectively."
b. "Nursing assessment data are used only to provide information about the effectiveness of your
medical care."
c. "Nurses use data from their patient's physical assessment to determine a patient's educational needs."
d. "Information gained from physical assessment helps nurses better understand their patients'
emotional needs." - correct answer ✔✔ANS: B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not just
the patient's medical care. Assessment data help to evaluate the effectiveness of medications and to
determine a patient's health care needs, including the need for patient education. Nurses also use
assessment data to identify patients' psychosocial and cultural needs.
Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the
patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He
performs proper identification of the patient before he auscultates her lungs. Which critical health
assessment step was not performed?
a. Running warm water over stethoscope for patient comfort
b. Cleaning stethoscope with Betadine
c. Using alcohol-based hand disinfectant
d. Cleaning stethoscope with alcohol - correct answer ✔✔ANS: D
Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is
used. The stethoscope should be cleaned before use on each patient. Running water over the
stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damage the
equipment. Hand sanitizer is not an approved cleaning product.
Which is the best examination position for a complete geriatric physical examination on a weak patient
with bilateral basilar pneumonia?
,a. Prone position
b. Sims' position
c. Supine position
d. Lateral recumbent - correct answer ✔✔ANS: C
This is the most normally relaxed position. It will not compromise the patient's breathing because it is
likely compromised with pneumonia. If the patient becomes short of breath easily, raise the head of the
bed. This position would be easiest for an elderly weak person to get into position for an examination.
Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory
difficulties. Sims' position is used for assessment of the rectum and the vagina.
During an annual gynecological examination, a college student discusses her upcoming college break at a
tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the
importance of skin cancer prevention education by discussing which evidence-based prevention health
topic?
a. Applying water-based sunscreen only before swimming
b. Using tanning bed daily for 7 days before college break trip
c. Applying broad-spectrum sunscreen of SPF 5
d. Taking extra precautions in the sun secondary to the prescription - correct answer ✔✔ANS: D
Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient should be
educated about the need for sun protection such as wide-brimmed hats, use of broad-spectrum
sunscreen of SPF 15 or greater, not tanning during midday, and not using tanning beds. Broad-spectrum
sunscreens should be applied 15 minutes before going into the sun and after swimming or perspiring.
Tanning parlors, sunlamps, etc., should be avoided. Sunscreens with SPF of 15 or greater should be used.
A head and neck physical examination is completed on a 50-year-old female patient. All physical findings
are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory
tests would the nurse expect to be ordered?
a. Liver function test
b. Lead level
c. Thyroid-stimulating hormone test
d. Complete blood count - correct answer ✔✔ANS: C
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has
jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.
, A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the basis of the
illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse
documents the varicellar lesions as which type of skin lesion?
a. Vesicle
b. Wheal
c. Papule
d. Pustule - correct answer ✔✔ANS: A
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1 cm.
Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They are
common with bug bits and hives. Papules are palpable, circumscribed, solid elevations in the skin that
are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are filled with pus.
A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately
asked about how the injury occurred, the student described falling on the playground. Upon suspecting
abuse, the school nurse's best next action is which of the following?
a. Interviewing the patient in the presence of his/her teacher
b. Ignoring the findings because child abuse is a declining problem
c. Realizing that abuse victims usually report abusive situations
d. Contacting Social Services and reporting suspected abuse - correct answer ✔✔ANS: D
Most states mandate a report to a social service center if nurses suspect abuse or neglect. When abuse
is suspected, the nurse interviews the patient in private. Abuse of children, women, and older adults is a
growing health problem. It is difficult to detect abuse because victims often will not complain or report
that they are in an abusive situation.
A nurse identifies Pediculosis humananus capitis. Considering the possible complications of treatment,
the nurse knows to not use which of the following treatment products?
a. Fine-toothed comb
b. Pediculicide
c. Lindane-based shampoo
d. Vinegar hair rinse - correct answer ✔✔ANS: C
Products containing lindane, a toxic ingredient, often cause adverse reactions. Instruct patients who
have head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water,
comb thoroughly with a fine-toothed comb, and discard the comb. A dilute solution of vinegar and water
helps loosen nits.
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