ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 5 : Adult Health and Nutritional Assessment Questions
Question 1 of 5
A nurse is conducting a health assessment of an adult patient when the patient asks, Why do you need all this health information and who is going to see it? What is the nurses best response?
Correct Answer: B
Rationale: Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used. Medical records allow access to health care providers who need the information to provide patients with the best possible care, and the records are always held in a secure environment. Telling the patient not to worry minimizes the patients concern regarding the safety of his or her health information and a wide variety of people should not have access to patients health information. Health information should not be placed on Web sites and health records are not destroyed every 2 years.
Question 2 of 5
The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?
Correct Answer: D
Rationale: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.
Question 3 of 5
You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?
Correct Answer: A
Rationale: Few patients will discuss the topic of abuse unless they are directly asked.
Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you? The other options are incorrect because they are not the best way to illicit information about possible abuse in a direct and appropriate manner.
Question 4 of 5
You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response?
Correct Answer: A
Rationale: Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patients care plan. The nurse should address the patients concerns directly and avoid casting doubt on the thoroughness of the physician.
Question 5 of 5
You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?
Correct Answer: A
Rationale: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.