TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 08: Health Assessment Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse admits the patient with mild chest pain from the emergency department. Which
should the nurse implement first to gain patient cooperation during a physical assessment? a. Explain the procedure and its purpose. b. Perform assessment in stages over the day. c. Complete assessment within 3–5 minutes. d. Assess painful areas before nontender areas. ANS: A
First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. The nurse will assess painful and tender areas last. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting
pallor and a slight bluish color. Which would the nurse implement first? a. Provide a warm heating pad. N b. Collaborate with the health care provider. c. Assess the patient’s oxygen saturation. d. Check for restricted venous return. ANS: C
Nail beds in a patient with light skin are a view of the patient’s capillary bed at the periphery. Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. The nurse would assess the oxygenation more thoroughly and intervene if needed. A heating pad is not warranted. The nurse will collaborate with the provider, but needs more data first. Since this is a problem in the arterial blood flow, checking venous return is not indicated. DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a
level of consciousness within normal limits? a. States name, age, and date but not location. b. Is lethargic; responds logically to questions. c. Responds verbally, but words are unintelligible. d. Responds to questions spontaneously; is alert and oriented. ANS: D
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