Answered step-by-stepHEALTH ASSESSMENT LAB CHOOSE THE CORRECT ANSWER 1 – Ambulate…HEALTH ASSESSMENT LABCHOOSE THE CORRECT ANSWER1 – Ambulate progressively with tripod cane *Correct Nursing DiagnosisIncorrect Nursing Diagnosis 2. Which of the following is most likely to lead to an inaccurate diagnosis of the patient? * asking open-ended s and allowing the patient to speak freely  obtaining information about multiple systems and complaints  poor communication and interviewing skills  learning about the patient’s complete medical history 3. A nurse is preparing a plan of care for a client who is a Jehovah’s Witness. The client has been told that the surgery is necessary. The nurse considers the client’s religious preferences in developing the plan of care and documents that: * Blood products cannot be administered.  Surgery is strictly prohibited.  Giving any medication is not allowed.  Alternative medicines can be advised 4 Which of the following is an appropriate evaluation for patient’s with fever? * Goal met: patient’s fever increased from 38 centigrade to 39 centigrade  Goal met: patient’s fever decreased from 38 centigrade to 37. 9 centigrade  Goal met: patient’s fever remained at 38 centigrade  Goal met: patient’s fever went down from 38 centigrade to normal body temperature 37 centigrade 5. The nurse gives his or her honest feedback about what he /she sees of feels * Confrontation  Empathy  Clarification  Interpretation – Which of the following is an appropriate evaluation for patient experiencing pain? * Goal partially met: patient’s pain score decreased from 10 to 7  Goal partially met: patient’s pain score remained at pain score of 10  Goal met: patient’s pain score decreased from 10 to 9  Goal met: patient’s pain score increased from 8 to 10 – Asking patient, “Tell me how can I help you?” is an example of * Open-ended   Closed or Direct  – The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? * An acceptance of treatment  Client understanding of the preoperative procedures  Reflecting cultural value  Client agreement to the required procedures – During your interview with a female client, the client verbalizes that she feels a sense of fulfillment for being able to provide for her family’s needs and contribute to the ongoing income-generating project in her community. What inference can most likely be drawn from the client’s verbalization? * Ego integrity is apparent.  Acceptance of self is not clearly articulated in the statement.  Her fulfillment reflects a sense of generativity.  There is a need to further assess the client in terms of engagement with older persons. – Which of the following is an independent nursing interventions for patient with fever? * Performing of Tepid Sponge Bath  Administration of paracetamol  Increasing patient’s Intravenous Fluids  Requesting for blood works In which step of the nursing process do you document all that you did for the client? * Planning  Nursing diagnosis  Assessment  Implementation  Evaluation Which of the following is an expected immediate active nursing diagnosis for post-operative patient? * Risk for infection  Knowledge deficit regarding post-operative procedures  Acute Pain  Fluid volume deficit related to blood loss Which of the following is the next step to do for the not met goals during evaluation? * Render overtime in order to achieve the goals  Apologize to patient for not meeting the goals  Endorse to the incoming nurse the not met goals for continuity of care  Update the physician through phone calls regarding not met goals Which of the following is an appropriate nursing intervention for patient suffering with severe pain? * Immediately refer the patient’s pain experience with the physician on duty  Take a complete history why patient is experiencing pain and report to the physician during doctor’s visit  Inform the patient to wait for the doctor’s visit  Instruct patient to drink his or her own stocks of over-the-counter pain reliever Mina is having labor pains and thinks that she will give birth anytime soon. She is at 37th week of pregnancy. Mina’s pregnancy is * term  preterm  post term  multiple Alita goes to a health center for prenatal check-up. When asked, she says that the first day of her last menstruation was last January 11, 2022. She verbalizes, “Pang-apat na pagbubuntis ko na ito. Tatlo na ang anak ko, ang panganay ay kambal at 7 months lang noong ipanganak ko. Ang isa ay husto sa buwan. Nakunan ako noong 2018, bale 7 weeks pa lang ang tiyan ko noon.” Alita’s LMP as the data, will be included in which of the following parts of the health history? * Present obstetric history  Past obstetric history  Patient’s profile  Past health history Which of the following is an expected goals and outcomes for patient with difficulty of breathing? * Absence of dyspnea  To lower the respiratory rate of patient to 20 cpm  Patient maintains an effective breathings pattern, as evidenced by relaxed breathing at normal rate and depth and absence dyspnea  Normal rate of breathing Which of the following is the correct sequence for the nursing care process? * Planning, Assessment, Diagnosis, Intervention and Evaluation  Diagnosis , Planning, Assessment, Intervention and Evaluation  Assessment , Planning, Diagnosis, Intervention and Evaluation  Assessment ,Diagnosis, Planning, Intervention and Evaluation Respiratory rate of 36 after walking length of hall unassisted * Subjective  Judgement or conclusion  Objective This is the most pertinent data gathered during the interview * Patient’s history  Patient’s physical exam findings  Patient’s laboratory exam  Patient’s outlook in life It reflects usual expectation of interventions for clinical patient. * Assessment  Outcome Identification  Evaluation  Planning  Nursing diagnosis  Implementation Patient is becoming increasingly agitated * Judgement or conclusion  Subjective  Objective Which of the following is not a correct statement of outcome criteria? * Ambulates the length of the hallway without shortness of breath, dizziness and faintness before discharge.  Demonstrate proper self-injection with insulin after the teaching session  Verbalizes fears and concerns regarding surgical procedures  Consumes 80 to 100% of meals served within 3 days As a pediatric nurse Nurse Melissa notes that the following are major content differences on getting the pediatric history except: * Immunization  Prenatal and Birth History  Developmental History  Nutrition The child has the ability to add important data to the history. Pose s about school, friends or activities directly to the child * School age  Infant  Preschool  toddler The following information is recorded in the health history: “The patient completed 12th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week.” Which of these categories does it belong to? * Present Illness  Review of Systems  Chief complaint  Social History Which of the following client can provide an adequate health history when being asked by the nurse in emergency room? * a geriatric client diagnosed with dementia  a 5 year old client with autism  an adult obese client  a comatose client with GCS of 3 Risk for infection related to second-degree burns on right hand. * Incorrect Nursing Diagnosis  Correct Nursing Diagnosis Which of the following actions is most appropriate during interview? * Use “Why” s to seek clarification of unusual symptoms or behavior  Stop the patient each time something is said that is not understood.  Spend more time listening to the patient than talking  Use medical jargon to orient the patient to his condition Which of the following is considered an activity of daily living? * Dressing  Preparing food  Bathing  All are correct Begin to establish rapport with the patient by conveying a caring interested attitude * Introductory Phase or Orientation Phase  Maintenance Phase or Working Phase  Preparatory Phase or Preinteraction Phase  Concluding Phase or Termination Phase . At what step of the nursing process does the care provider document the client health problems? * Nursing diagnosis  Assessment  Evaluation  Implementation  Planning . In gathering health history, what is the most important part of communication that the nurse should possess? * speaking clearly and directly  use of touch  asking follow up s  listening What is an example of assessment of the review of hematologic system? * easy bruising  all the above  past transfusion.  anemia . When a client’s chief complaint has been identified, a nurse should ask which of the following? * Factors that worsen the chief complaint  Impact of the chief complaint to the patient  Factors that decrease the severity of the chief complaint  All of the choices Which of the following statement best describes nursing care process? * Nursing care process is a never ending process  Nursing care process is a hospital based process to solve patient’s concerns  Nursing care process is dynamic process for health care professionals  Nursing care process is a systematic and patient centered care process in order to address patient’s health problems Impaired verbal communications related to inability to speak dominant English language * Incorrect Nursing Diagnosis  Correct Nursing Diagnosis Alita goes to a health center for prenatal check-up. When asked, she says that the first day of her last menstruation was last January 11, 2022. What is the AOG if the date of consultation is February 28, 2022? * 6 weeks  5 6/7 weeks  6 6/7 weeks  7 weeks The child wants to know functional aspects – how things work and why things are done. * School-age  preschooler  Infancy  Toddler Establish a verbal contract with the patient, incorporating the goals of the interview * Introductory Phase or Orientation Phase  Maintenance Phase or Working Phase  Preparatory Phase or Preinteraction Phase  Concluding Phase or Termination Phase Which of the following data should be included as source of history in a 3-year old client? * Impression of reliability of source at the start of the interview  Relationship to the child of the one providing the information  Overall impression of the child  Language used to gather information Which of the following information can be included both in the demographic data and the social history? * Sexual History  Habit  Diet  Education this child is more objective and realistic * Toddler  School-age  preschooler  Infancy Which of the following is dependent nursing intervention? * Performing of Tepid Sponge Bath  Taking of patient’s vital signs  Monitoring of patient’s intake and output  Administration of medication  Health ScienceScienceNursingShare

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