ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 5 Questions
Question 1 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 2 of 5
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate?
Correct Answer: B
Rationale: Individuals who have a BMI between 25 and 29.9 are considered overweight. Obesity is defined as a BMI of greater than 30 (WHO, 2011). A BMI of 45 would indicate extreme obesity.
Question 3 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 4 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 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.