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 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.
Question 2 of 5
A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment?
Correct Answer: D
Rationale: Illness may cause a spiritual crisis and can place considerable stresses on a persons internal resources. The term spiritual environment refers to the degree to which a person has contemplated his or her own existence. The other listed options may be right, but they are not the most important reasons for a nurse to assess a patients spiritual environment.
Question 3 of 5
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?
Correct Answer: B
Rationale: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the patients religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition.
Question 4 of 5
You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the patients neck?
Correct Answer: C
Rationale: Palpation is a part of the assessment that allows the nurse to assess a body part through touch. Many structures of the body (superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum), although not visible, may be assessed through the techniques of light and deep palpation. The other options are incorrect because lymph nodes are not assessed through inspection, auscultation, or percussion.
Question 5 of 5
In your role as a school nurse, you are working with a female high school junior whose BMI is 31 . When planning this girls care, you should identify what goal?
Correct Answer: B
Rationale: A BMI of 31 is considered clinically obese; dietary and exercise modifications would be indicated. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29.9 are considered overweight; those with a BMI of 30 or greater are considered to be obese.