Test Bank for Medical Surgical Nursing, 2nd Edition, Osborn

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Chapter 06
Question 1
Type: MCSA
While conducting a health assessment, the nurse documents a patient’s response
under the heading “chief complaint.” Which part of the assessment is the nurse
conducting?
1.
2.
3.
4.
History of present illness
Family history
Psychosocial history
Past medical history
Correct Answer: 1
Rationale 1: The history of the present illness includes information about what brought
the patient to the health care provider. The reason is usually written verbatim in the
health record and often becomes the chief complaint.
Rationale 2: The patient’s chief complaint is not part of the family history.
Rationale 3: The patient’s chief complaint is not part of the psychosocial history.
Rationale 4: The patient’s chief complaint is not part of the past medical history.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-1
Question 2
Type: MCSA
A patient comes to the emergency department and states, “I am having chest pain and I
feel short of breath.” How is the data the patient has just given the nurse classified?
1.
2.
3.
4.
Nonspecific
Objective
Factual
Subjective
Correct Answer: 4
Rationale 1: Nonspecific is not a term used to describe types of assessment data.
Rationale 2: Objective data is information collected when the nurse uses the senses:
observation, palpation, auscultation, percussion, and smell.
Rationale 3: Factual is not a term used to describe types of assessment data.
Rationale 4: Subjective data is information the patient provides to the nurse.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-3
Question 3
Type: MCSA
The nurse has completed the collection and analysis of data from a patient assessment.
What is the nurse’s next action?
1.
2.
3.
4.
Evaluate outcomes from care.
Plan care.
Determine patient care goals.
Formulate nursing diagnoses.
Correct Answer: 4
Rationale 1: Evaluation occurs after care is implemented.
Rationale 2: Planning occurs later in the nursing process.
Rationale 3: Determining patient goals is a later step of the nursing process.
Rationale 4: Once data is collected, it is used to formulate nursing diagnoses, which is
the next step of the nursing process.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-2
Question 4
Type: MCSA
The nurse asks the patient, “What brings you to the hospital today?” What is the nurse’s
rationale for using this type of question?
1.
2.
3.
4.
It acknowledges agreement between the patient and the nurse.
It elicits specific information.
It is useful for introducing a subject in general terms.
It helps to clarify information.
Correct Answer: 3
Rationale 1: The question does not acknowledge agreement between the patient and
the nurse. The nurse’s summary at the end of the interview acknowledges agreement.
Rationale 2: Direct questions are used to elicit specific information.
Rationale 3: The question is an open-ended question and asks for narrative information
by stating the topic in general terms. It is used to introduce a topic.
Rationale 4: The question does not help to clarify information.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-3
Question 5
Type: MCSA
While conducting a health history, the nurse nods her head as the patient is talking.
What is the nurse’s primary rationale for this action?
1.
2.
3.
4.
It conveys acknowledgment of the patient’s feelings.
It helps to reduce the patient’s anxiety level.
It encourages the patient to continue talking.
It allows the nurse time to observe the patient’s nonverbal cues.
Correct Answer: 3
Rationale 1: Empathy is used to acknowledge the patient’s feelings.
Rationale 2: Explanation will reduce the patient’s anxiety level.
Rationale 3: Nodding the head encourages the patient to tell the nurse more and is
considered facilitation.
Rationale 4: The use of silence will allow the nurse time to observe the patient’s
nonverbal cues.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-3
Question 6
Type: MCSA
A patient tells the nurse that he has a history of back pain that is controlled with yoga
and herbal supplements. How would the nurse document this information?
1. The patient does not believe in Western medicine.
2. The patient has strong spiritual beliefs.
3. The patient uses some alternative forms of medicine to treat illness.
4. The patient uses stress reduction techniques to control back pain.
Correct Answer: 3
Rationale 1: Western medicine is the type of health care traditionally provided in the
United States and includes diagnostic testing, treatments, and medications. There is no
indication that the patient does not believe in Western medicine.
Rationale 2: The strength of the patient’s spiritual beliefs cannot be assessed by this
information alone.
Rationale 3: The use of herbal supplements to relieve back pain is a form of
complementary or alternative medicine. The nurse must assess this practice, as some
“natural cures” are ineffective and some can interfere with prescribed medications.
Rationale 4: There is not enough information to make this statement. The patient may
use yoga as a strengthening exercise for back muscles. The herbs may not be taken for
stress reduction.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 06-01
Question 7
Type: MCSA
The nurse introduces herself and shakes the patient’s hand, then sits so as to maintain
eye contact during the health interview. What do the nurse’s actions demonstrate?
1.
2.
3.
4.
Facilitation
Negative nonverbal messages
Positive nonverbal messages
Empathy
Correct Answer: 3
Rationale 1: Facilitation would occur if the nurse nodded the head to encourage the
patient to continue talking.
Rationale 2: Negative nonverbal messages include tense posture, yawning, and
avoiding eye contact. The nurse’s actions are not negative.
Rationale 3: Positive nonverbal messages enhance the relationship with the patient and
include eye contact and equal-status seating.
Rationale 4: Empathy is acknowledging a patient’s feelings with a statement of
understanding.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-3
Question 8
Type: MCSA
During the health history, a patient tells the nurse that she is in an abusive relationship
and is fearful of getting hurt if her husband finds out that she told the nurse. Which
response by the nurse is most appropriate for this patient?
1.
2.
3.
4.
“Don’t worry. They only strike back when they are angry.”
“Are you saying that you are in danger?”
“I would get an attorney if I were you.”
“Remember, what goes around comes around.”
Correct Answer: 2
Rationale 1: This answer does not promote the patient’s health.
Rationale 2: The nurse needs to clarify what the patient is explaining, and the best
response would be to clarify if the patient is saying she is in danger.
Rationale 3: The nurse should not offer legal advice to the patient.
Rationale 4: This statement dismisses the patient’s concern for her safety and does not
promote her health.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6-3
Question 9
Type: MCSA
During an assessment, the patient describes shoulder pain. The nurse responds, “So,
you have this shoulder pain when you eat fried foods or ice cream, is that correct?” The
nurse is using which interview technique?
1.
2.
3.
4.
Facilitation
Empathy
Interpretation
Summary
Correct Answer: 3
Rationale 1: Facilitation is a technique that would encourage the patient to continue
talking.
Rationale 2: Empathy acknowledges the patient’s feelings with a statement of
understanding to help the patient feel accepted.
Rationale 3: Interpretation links events or implies a cause, which is what the nurse is
doing when responding to this patient.
Rationale 4: Summary occurs at the end of the interview, when the nurse summarizes
the perception of the patient’s health problem from the information gained during the
interview.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-3
Question 10
Type: MCSA
The nurse notices a patient has a strong, foul body odor. The patient tells the nurse he
has trouble getting in and out of the bathtub. Which areas of the physical assessment
does this information address?
1.
2.
3.
4.
Behavior and pain
Nutritional assessment, mental status, and behavior
Physical appearance, height, and weight
Functional assessment, physical appearance, and mobility
Correct Answer: 4
Rationale 1: The patient did not say that his inability to use the bathtub was associated
with pain, and the nurse should be careful not to make this assumption.
Rationale 2: An inability to use the bathtub does not speak specifically to nutrition,
mental status, or behavior.
Rationale 3: The inability to use the bathtub does affect physical appearance. The
patient did not mention that the tub was too small or that his weight made using it
difficult, so these issues cannot currently be considered a factor. The nurse must be
careful not to make assumptions without data.
Rationale 4: The patient states difficulty with using a bathtub, which provides
information relevant to functional assessment, physical appearance, and mobility.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-4
Question 11
Type: MCSA
Prior to palpating the abdomen of a patient with several skin lesions, the nurse puts on
a pair of gloves. The patient asks, “What are the gloves for?” Which is the best
response the nurse can give the patient?
1. “Gloves are considered a standard precaution to provide protection to the health care
provider during an exam.”
2. “I don’t want to catch anything from you.”
3. “I prefer to wear gloves when touching people.”
4. “The gloves help me to grip my equipment better.”
Correct Answer: 1
Rationale 1: The nurse needs to use standard precautions throughout the entire
physical examination and should explain this to the patient. Gloves are particularly
important when skin lesions are present.
Rationale 2: The nurse should not make the patient feel “dirty” or “bad” when answering
this question.
Rationale 3: This should not be the reason the nurse is wearing gloves and is not an
appropriate answer.
Rationale 4: This statement is not accurate.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-4
Question 12
Type: MCMA
While performing percussion in a physical examination, the nurse elicits dullness. Which
structure is the nurse likely percussing?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Intestines
Lungs
Pelvic bone
Liver
Kidney
Correct Answer: 4,5
Rationale 1: Tympany is the percussion sound heard over air-filled intestines.
Rationale 2: Resonance is the percussion sound heard over normal lungs.
Rationale 3: Flatness is the percussion sound heard over muscle and bone.
Rationale 4: Dullness is the percussion sound heard over large, solid organs such as
the liver.
Rationale 5: Dullness is the percussion sound heard over large, solid organs such as
the kidney.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-4
Question 13
Type: MCSA
A patient in the unit has a blood pressure of 55/30, is lethargic, has slurred speech, and
is unable to get back to bed from the bathroom. The nurse calls for a rapid response
team. Which component of critical thinking is the nurse exhibiting?
1.
2.
3.
4.
Analysis of situation, distinguishing normal from abnormal
Selection of alternative by developing outcomes and plans
Collection of information, subjective and objective
Evaluation of situation, determination of outcomes achieved
Correct Answer: 1
Rationale 1: Analysis of the situation is the second component of critical thinking. This
component includes the ability to distinguish normal from abnormal.
Rationale 2: Selection of alternatives is the fourth step in the critical thinking process
and is used when developing outcomes and plans.
Rationale 3: Collection of information is the first step in the critical thinking process and
is used during the health assessment.
Rationale 4: Evaluation of the situation is the last step of the critical thinking process
and is used to determine if the expected outcomes have been achieved.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6-5
Question 14
Type: MCSA
The nurse and a patient are discussing a variety of options that may help alleviate a
health problem. The nurse and patient are involved in which step of the critical thinking
process?
1.
2.
3.
4.
Evaluation
Collection of information
Generation of alternatives
Analysis of the situation
Correct Answer: 3
Rationale 1: Evaluation is the last step of the process and is done to determine whether
the expected outcomes have been achieved.
Rationale 2: Collection of information begins with the interview and continues
throughout the entire health assessment.
Rationale 3: Generation of alternatives occurs when options are identified and priorities
are established. The nurse and patient work together to discuss the options so the
patient can make an informed decision.
Rationale 4: Analysis of the situation follows the collection of information and helps
distinguish normal from abnormal findings.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6-5
Question 15
Type: MCMA
The nurse is reviewing the outcomes of a patient’s plan of care. Which portions of the
critical thinking process are used in this evaluation?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Revision of cues
Generation of alternatives
Analysis of the situation
Selection of alternatives
Collection of information
Correct Answer: 3,4,5
Rationale 1: Cues are bits of information that may hint at the possibility of a health
problem. The cues are static and cannot be revised.
Rationale 2: Each step of the critical thinking process is used in evaluation. The nurse
may need to generate new alternatives to address unmet or undesirable outcomes.
Rationale 3: Each step of the critical thinking process is used in evaluation. The nurse
reanalyzes the situation to see if any omissions or misinterpretations have occurred.
Rationale 4: Each step of the critical thinking process is used in evaluation. The nurse
uses critical thinking to determine if the alternatives selected were appropriate and if
any omissions occurred.
Rationale 5: Each step of the critical thinking process is used in evaluation. The nurse
uses critical thinking to determine if all pertinent information was collected and if any
misinterpretation occurred.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6-5
Question 16
Type: FIB
A 54-year-old patient reports that she smokes a pack and a half of cigarettes daily and
has been smoking since she was 16 years old. The nurse would record a smoking
history of ______ pack-years.
Standard Text:
Correct Answer: 57
Rationale : This patient has been smoking for 38 years (54-16). 38 × 1.5 = 57 packyears.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-1
Question 17
Type: MCMA
The nurse is using the technique of inspection during a patient’s physical examination.
Which findings are possible using this technique?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
The patient’s left leg is larger than the right leg.
The patient’s abdomen is scaphoid.
The patient has a strong radial pulse.
The patient has difficulty extending the right arm above the head.
The patient has periorbital edema.
Correct Answer: 1,2,4,5
Rationale 1: The nurse can see the differences in size using inspection.
Rationale 2: The nurse can see the contours of the abdomen using inspection.
Rationale 3: To assess the radial pulse, the nurse must use palpation.
Rationale 4: Difficulty in movement can be assessed through inspection.
Rationale 5: Edema can be assessed through inspection, although it must be graded
through palpation.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-4
Question 18
Type: MCMA
The nurse is preparing to use auscultation as part of a patient’s physical examination.
Which techniques should the nurse use?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Pressing the bell of the stethoscope firmly on the skin to hear muffled tones
Using the diaphragm of the stethoscope to hear normal lung sounds
Placing the diaphragm of the stethoscope firmly against the patient’s gown
Focusing on one sound at a time
Using the bell of the stethoscope to hear low-pitched sounds
Correct Answer: 2,4,5
Rationale 1: The bell of the stethoscope becomes a diaphragm when pressed firmly on
the skin. The skin under the bell stretches, creating a surface that reduces audible
vibratory sensations.
Rationale 2: The diaphragm of the stethoscope is best for hearing high-pitched sounds
such as normal lung sounds.
Rationale 3: The stethoscope should be placed on bare skin. The patient’s gown or bed
sheets will produce sounds that interfere with body sounds.
Rationale 4: A variety of sounds can be heard when the nurse listens at each
auscultatory landmark. The nurse should focus on one sound at a time.
Rationale 5: The bell is the best side of the stethoscope for hearing low-pitched sounds
such as heart murmurs.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 06-04
Question 19
Type: MCMA
The nurse is using blunt percussion to assess a patient who was involved in a motor
vehicle accident. The nurse would use this technique to assess for injury to which
organs?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Kidney
Liver
Lungs
Bladder
Heart
Correct Answer: 1,2
Rationale 1: Blunt percussion is often used as a quick screen for inflammation or
damage to the kidney.
Rationale 2: Blunt percussion over the liver that elicits pain would indicate injury.
Rationale 3: Blunt percussion is not used to assess the lungs.
Rationale 4: Indirect percussion is used to assess the bladder.
Rationale 5: Blunt percussion is not used to assess the heart.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-4
Question 20
Type: MCSA
Using critical thinking, the nurse assesses that a patient is not a reliable historian. How
should the nurse proceed?
1.
2.
3.
4.
Stop the assessment because all data is invalid.
Document that the patient is not answering questions truthfully.
Ask different questions to assess the same information.
Document the information just as the patient reports it.
Correct Answer: 3
Rationale 1: There are many parts of assessment that do not depend on the patient
being an accurate historian.
Rationale 2: Being an unreliable historian does not mean that the patient is not truthful.
In some cases it indicates that the patient has memory or hearing issues.
Rationale 3: The nurse can assess information in a variety of ways. Asking different
questions to elicit information is a valid technique.
Rationale 4: The nurse should not taint the data set by recording obviously inaccurate
data. Further attempts to verify data should be taken.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-5
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