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
You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient?
Correct Answer: C
Rationale: Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. MyPlate is not explicitly culturally sensitive. Nursing resource books do not usually have culturally sensitive dietary specific material. A Greek cookbook would not be an appropriate clinical resource.
Question 2 of 5
In the course of performing an admission assessment, the nurse has asked questions about the patient's first- and second-order relatives. What is the primary rationale for the nurse's line of questioning?
Correct Answer: D
Rationale:
To identify diseases that may be genetic, communicable, or possibly environmental in origin, the interviewer asks about the age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins). This is a priority over the number of living relatives, sources of support, or health literacy, though each of these may be relevant.
Question 3 of 5
The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems?
Correct Answer: A,B,E
Rationale: In general, the following conditions are included in a family history: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies ???¾?±?????²?µ?½?½?¾?¹, alcoholism, and obesity. Psoriasis and hypervitaminosis do not have genetic etiologies.
Question 4 of 5
The nurse is performing the process of inspection during an assessment. What nursing action should the nurse include during this phase?
Correct Answer: B
Rationale: It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. It is specific information, not general information, that is being gathered. Writing while observing can be a conflict for the nurse. It is not necessary or appropriate to keep the assessment concealed from the patient.
Question 5 of 5
During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?
Correct Answer: C
Rationale: Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.