Chapter 24 Adapting Health Assessment to the Hospitalized Patient

Chapter 24  Adapting Health Assessment to the Hospitalized Patient

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Development of which complication is considered a never event?
a.
Fever
b.
Atelectasis
c.
Pressure ulcer
d.
Thrombophlebitis

ANS: C

Feedback
A
Fever is a common occurrence in ill patients that may indicate inflammation or infection.
B
Atelectasis is collapse of alveoli that may occur due to the patient’s hypoventilation, such as after surgery.
C
Pressure ulcer is termed a never event because it refers to preventable, medical errors that should never occur.
D
Thrombophlebitis is inflammation of veins that may occur due to immobility.

DIF: Cognitive Level: Understand REF: 545
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

2. For which patient does the nurse make assessment of the oral mucous membrane a priority?
a.
The patient who has an arteriovenous (AV) fistula
b.
The patient who has a gastrostomy tube
c.
The patient who uses a Ventimask
d.
The patient who has a colostomy

ANS: B

Feedback
A
The AV fistula is required by patients who need hemodialysis for kidney failure. They are able to drink fluids by mouth.
B
Which patient can drink fluids by mouth is the distinguishing fact. This patient has this gastrostomy tube because he or she has difficulty swallowing. Thus this patient may not have fluids by mouth, which increases the risk for dry mucous membranes and makes the assessment most important compared with the other listed patients.
C
The Ventimask fits over the nose and mouth to deliver oxygen. This patient is able to drink fluids by mouth.
D
This patient has had part or all of the colon removed, but this patient is able to drink fluids by mouth.

DIF: Cognitive Level: Apply REF: 550
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

3. How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes?
a.
Palpate the popliteal pulse of the left leg.
b.
Palpate the posterior tibial pulse of the left leg.
c.
Assess movement and sensation of the left toes.
d.
Assess the capillary refill of the left toes.

ANS: D

Feedback
A
This pulse is above the foot and does not indicate perfusion of the foot.
B
The pulse is not palpable because it is covered by the cast.
C
This assessment is important for this patient but assesses neurologic function rather than perfusion.
D
The presence of capillary refill in less than 2 seconds indicates perfusion of the left foot when the dorsalis pedis pulse cannot be palpated.

DIF: Cognitive Level: Understand REF: 553
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

4. A nurse uses the Glasgow Coma Scale to assess which patient?
a.
The patient who has a new onset of quadriplegia
b.
The patient who has tonic-clonic seizures
c.
The patient who requires stimuli for responses
d.
The patient who has dementia

ANS: C

Feedback
A
Although this patient is paralyzed, he or she is conscious. The Glasgow Coma Scale would not yield useful data about this patient.
B
Although this patient may be unconscious during seizures, consciousness will return. The Glasgow Coma Scale would not yield useful data about this patient.
C
The Glasgow Coma Scale is applicable only to patients who are unconscious, meaning they do not respond unless stimulated in some way from touch to pain.
D
This patient is not unconscious. The Glasgow Coma Scale would not yield useful data about this patient.

DIF: Cognitive Level: Apply REF: 555-556
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems