A patient tells the nurse that he is very nervous, nauseated and that he "feels hot". This type of data would be considered: - ANS subjective
Because the physical environment in which an interview takes place is an important consideration for the success of an interview, the interviewe...
A patient tells the nurse that he is very nervous, nauseated and that he "feels hot". This type of
data would be considered: - ANS subjective
Because the physical environment in which an interview takes place is an important
consideration for the success of an interview, the interviewer should: - ANS reduce noise
by turning off televisions and cell phones
A nurse is taking complete health histories on all the patients attending a wellness workshop.
While conducting an interview with a patient, the nurse asks, "Can you tell me a little about
yourself?" This question is an example of: - ANS an open-ended question
During an interview, a parent of a hospitalized child is sitting in an open position. As the
interviewer begins to discuss the child's treatment, however, the parent suddenly crosses the
arms against the chest and crosses the legs. Based on the understanding that nonverbal modes
of communication provide clues to understanding feelings, the sudden change in body position
would suggest that the parent is: - ANS uncomfortable talking about his child's treatment
A 59-year-old patient is returning to the outpatient clinic for a follow up visit. The patient has a
history of ulcerative colitis. The patient states he has been having "black stools" for the last 24
hours. Which of the following would be the most complete way for the nurse to document the
patient's reason for seeking care? - ANS J.M. is a 59-year-old patient here for having
"black stools" for the past 24 hours.
Which of the following statements best describes the purpose of a health history? - ANS
to provide a database of subjective information about the patient's past and current health.
The inspection phase of the physical assessment: - ANS begins the moment you first
meet the person and develop a "general survey".
A patient is at the clinic for a physical examination. He states that he is "very anxious" about the
physical exam. What steps can the examiner take to make the patient more comfortable? - ANS
Appear unhurried and confident when examining the patient.
When performing a physical examination, safety must be considered to protect the examiner
and the patient against the spread of infection. Which of the following statements describes the
most appropriate actions the examiner should take when performing a physical examination? -
, ANS Wash hands at the beginning of the examination and any time that one leaves and
re-enters the room.
A 50-year-old patient who is taking anti-hypertensive medications returns to the clinic to have
their blood pressure (BP) checked. The last BP was 146/88. The BP reported to the nurse is
168/96. Both blood pressures were taken at the brachial site. Which of the following is true
regarding blood pressure assessment in this patient? Choose all that apply:
1. The patient should be allowed to adequately rest prior to assessing the blood pressure.
2. The width of the cuff should cover 40% of the circumference of the upper arm.
3. The position of the arm used for blood pressure assessment should be above the level of the
heart.
4. Goal blood pressure for this patient should be systolic less than 120 mm Hg and diastolic less
than 80 mmHg.
5. The last audible sound auscultated during blood pressure assessment should be recorded for
the systolic reading.
6. An unsupported arm may be used for an accurate blood pressure measure - ANS 1, 2,
4
While caring for a patient with heart disease, the nurse notices an irregularity in the rhythm of
the patient's radial pulse. The previous assessment did not reveal an irregular pulse. What
would be the BEST action to take? - ANS count the patient's apical pulse for one minute
Which of the following statements is true regarding use of the tympanic thermometer? - ANS
The practitioner needs to wait at least 10 minutes to obtain the temperature if the patient has
been outdoors.
Which of the following is true regarding an oral temperature? - ANS The thermometer
should be placed in the posterior sublingual pocket of the mouth.
The nurse is taking a blood pressure on a patient; the patient's baseline blood pressure is
unknown. The nurse does not have any previous information about the patient's blood pressure
measurements, nor is the patient able to give any information about previous blood pressure
readings. Which of the following techniques would be the MOST accurate way to measure this
patient's blood pressure? - ANS Inflate the blood pressure cuff 30 mm Hg above the point
at which the palpated pulse disappeared.
A patient is being seen in the clinic for "fainting episodes". The patient has a blood pressure of
150/90 in a lying position, 120/80 in a sitting position, and 90/60 in a standing position. How
should the nurse interpret these findings? - ANS The change in blood pressure readings
is called orthostatic hypotension.
In the article by Rakotz, 'Medical students and measuring blood pressure: Results from the
American Medical Association Blood Pressure Check Challenge', what are the consequences of
poor technique when measuring blood pressure? - ANS all of the above
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