Transition to BSN Quiz 1 PDF

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transition to bsn 1st online quiz for nurs 4100...

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Attempt Score, 100 out of 100 points Time Elapsed, 1 hour, 3 minutes out of 1 hour and 30 minutes Instructions, The quiz covers Jarvis chapters 1, 2, 3, 4, 5, 6, 7 & 32. You have 90 minutes to answer 50 questions. Results Displayed, All Answers, Submitted Answers, Correct Answers, Feedback, Incorrectly Answered Questions Question 1 2 out of 2 points

The nurse is providing instructions to newly hired graduates for the mini–mental state examination (MMSE). Which statement best describes this examination?

Selected Answer:, c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. Answers:, a. The MMSE is a useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. Scores below 30 indicate cognitive impairment.

Response Feedback:, The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

Question 2 2 out of 2 points

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?

Selected Answer:, c. To provide a database of subjective information about the patient’s past and current health Answers:, a. To document the normal and abnormal findings of a physical assessment b. To provide an opportunity for interaction between the patient and the nurse c. To provide a database of subjective information about the patient’s past and current health d. To provide a form for obtaining the patient’s biographic information

Response Feedback:, The purpose of the health history is to collect subjective data—what the person says about him or herself. The other options are not correct. Although conducting a health history allows the nurse an opportunity for interaction with the patient and a method for obtaining a patient’s biographic data, the purpose of the health history is to collect subjective data—what the person says about him or herself. The other options are not correct. The documentation of normal and abnormal findings of a physical assessment is part of the physical examination.

Question 3 2 out of 2 points

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?

Selected Answer:, a. Individual with shortness of breath and respiratory distress Answers:, a. Individual with shortness of breath and respiratory distress b. Patient with postoperative pain c. Individual with a small laceration on the sole of the foot d. Newly diagnosed patient with diabetes who needs diabetic teaching

Response Feedback:, First-level priority problems are those that are emergent, life-threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs). Postoperative pain, diabetic teaching for a patient newly diagnosed with diabetes, and a small laceration on sole of the foot are not considered first-level priority problems.

Question 4

2 out of 2 points

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation?

Selected Answer:, d. “Pick up the pencil in your left hand, move it to your right hand, and place it on the table.” Answers:, a. “How do you usually feel? Is this normal behavior for you?” b. “I am going to say four words. In a few minutes, I will ask you to recall them.” c. “Describe the meaning of the phrase, ‘Looking through rose-colored glasses.’” d. “Pick up the pencil in your left hand, move it to your right hand, and place it on the table.”

Response Feedback:, This patient appears to have symptoms of attention-deficit/hyperactivity disorder (ADHD) (restless, fidgeting, excess talking). The nurse should assess the patient’s attention span. Attention span is evaluated by assessing the individual’s ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span. Options A, B, and C do not assess attention span.

Question 5 2 out of 2 points

During an interview, a woman says, “I have decided that I can no longer allow my children to live with their father’s violence, but I just can’t seem to leave him.” Using interpretation, which would be the best response by the nurse?

Selected Answer:, d. “It sounds as if you might be afraid of how your husband will respond.” Answers:, a. “You are going to leave him?” b. “It sounds as though you have made your decision. I think it is a good one.” c. “If you are afraid for your children, then why can’t you leave?” d. “It sounds as if you might be afraid of how your husband will respond.”

Response Feedback:, The statement “It sounds as if you might be afraid of how your husband will respond” is linking events, making associations, and implying cause, which are what occur in interpretation. Interpretation also recognizes feelings and helps the person understand his or her own feelings in relation to the verbal message. The other statements do not reflect interpretation. The statement “You are going to leave him?” is a direct question, not an interpretation. The statements “If you are afraid for your children, then why can’t you leave?” and “It sounds as though you have made your decision. I think it is a good one” do not recognize the person’s feelings or link events, make associations, or imply cause. In addition, in the latter statement the nurse is providing his or her opinion which is inappropriate.

Question 6 2 out of 2 points

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?

Selected Answer:, c. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. Answers:, a. Patient denies usual childhood illnesses. b. Patient states he was a “very healthy” child. c. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. d. Patient states his sister had measles, but he didn’t.

Response Feedback:, This is the most specific statement about childhood illnesses. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles). When recording information about childhood illnesses, the nurse should avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles). Recording the patient was a very healthy child does not confirm or deny specific childhood illnesses and recording the patient stated his sister had measles but he didn’t does not address the other childhood illnesses. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Question 7 2 out of 2 points

A female patient has denied any abuse when answering the questions on an abuse assessment screening tool, but what finding by the nurse during the interview process is associated with IPV?

Selected Answer:, a. Depression Answers:, a. Depression b. Asthma c. Confusion d. Frequent colds

Response Feedback:, Abuse victims have significantly more depression, suicidality, post-traumatic stress disorder (PTSD), and problems with substance abuse. Abused women also have been found to have more chronic health problems, such as cardiovascular, endocrine, immune, gastrointestinal, and gynecologic problems. Asthma, confusion, and frequent colds are not problems associated with abuse.

Question 8 2 out of 2 points

What data should the nurse collect during the interview portion of a health assessment.

Selected Answer:, b. Subjective Answers:, a. Physical b. Subjective c. Objective d. Historical

Response Feedback:, The interview is the first, and really the most important, part of data collection. During the interview, the nurse collects subjective data; that is, what the person says about him or herself. Physical data is gathered in the physical examination portion of a health assessment. Historical data is gathered from the medical records. Objective data is what the nurse observes, this typically occurs during the physical examination, not the interview. During the interview, the nurse collects subjective data; that is, what the person says about him or herself.

Question 9 2 out of 2 points

In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?

Selected Answer:, c. Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors. Answers:, a. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. b. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. c. Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors. d. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.

Response Feedback:, The use of history forms and note-taking may be unavoidable. However, the nurse must be aware that note-taking during the interview has disadvantages, one of which is impeding the nurse’s observations of the patient’s nonverbal behavior. Note-taking often interrupts the patient’s narrative flow, rather than allowing them to keep their own pace. Note-taking can break eye contact and also shift the nurse’s attention away from the patient which can diminish the patient’s sense of importance.

Question 10 2 out of 2 points

The nurse is assessing an older adult’s functional ability. Which definition correctly describes one’s functional ability?

Selected Answer:, d. It refers to one’s ability to perform activities necessary to live in modern society. Answers:, a. It is the measure of the expected changes of aging that one is experiencing. b. It denotes an older person’s cognitive level. c. It describes the individual’s motivation to live independently.

d. It refers to one’s ability to perform activities necessary to live in modern society.

Response Feedback:, Functional ability refers to one’s ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting.

Question 11 2 out of 2 points

What information obtained by the nurse regarding a patient’s skin should the nurse record in the patient’s health history?

Selected Answer:, d. Patient denies any color change. Answers:, a. Lesion is noted on the lateral aspect of the right arm. b. Skin appears dry. c. No lesions are obvious. d. Patient denies any color change.

Response Feedback:, The purpose of the health history is to collect subjective data, or what the person says about him or herself, so should be limited to patient statements that the person says were or were not present. Skin appears dry, no lesions are obvious, and lesions noted on the lateral aspect of the right arm are all objective data, or things that nurse observed. The purpose of the health history is to collect subjective data, or what the person says about him or herself, so should be limited to patient statements that the person says were or were not present.

Question 12 2 out of 2 points

The nurse is admitting a patient with an addiction to alcohol to a treatment center. Which screening tool should the nurse use to assess for symptoms of alcohol withdrawal?

Selected Answer:, d. CIWA-Ar

Answers:, a. SMAST-G b. AUDIT c. TWEAK d. CIWA-Ar

Response Feedback:, The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is a tool used to assess and objectively measure the symptoms of alcohol withdrawal. The tool is quantified to measure the progress of withdrawal. The TWEAK, AUDIT, and SMAST-G are tools that assess for alcohol use or problems, not withdrawal.

Question 13 2 out of 2 points

When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?

Selected Answer:, a. “What cultural or spiritual beliefs are important to you?” Answers:, a. “What cultural or spiritual beliefs are important to you?” b. “Are you of the Christian faith?” c. “How often do you seek help from medical providers?” d. “Do you want to see a medicine man?”

Response Feedback:, The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.

Question 14 2 out of 2 points

During an interview, the nurse would expect that most of the interview will take place at what distance?

Selected Answer:, a. Social distance Answers:, a. Social distance b. Public distance c. Intimate zone d. Personal distance

Response Feedback:, Social distance, 4 to 12 feet, is usually the distance category for most of the interview. Public distance, over 12 feet, is too much distance; the intimate zone is inappropriate, and the personal distance will be used for the physical assessment. The intimate, personal public zones are inappropriate to conduct an interview. The intimate zone (1–1 ft.) is usually uncomfortable for people. The personal zone (1 to 4 ft.) will be used for the physical assessment. The public zone (12+ ft.) is too far away to allow for confidentiality of information or to express interest in someone.

Question 15 2 out of 2 points

What does the review of systems provide the nurse?

Selected Answer:, b. Information regarding health promotion practices Answers:, a. Information necessary for the nurse to diagnose the patient’s medical problem b. Information regarding health promotion practices c. Physical findings r/t each system d. An opportunity to teach the patient medical terms

Response Feedback:, The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double-check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices. The review of systems does not provide the physical findings of each body system, an opportunity to teach the patient medical terms, or the information necessary for the nurse to diagnose the patient’s medical problem.

Question 16

2 out of 2 points

The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. Which is the best way for the nurse to document the findings in the patient’s chart?

Selected Answer:, d. Use the words the child has said to describe how the injury occurred. Answers:, a. Document what the child’s caregiver tells the nurse. b. Rely on photographs of the injuries. c. Record what the nurse observes during the conversation. d. Use the words the child has said to describe how the injury occurred.

Response Feedback:, When documenting the history and physical findings of suspected child abuse and neglect, use the words the child has said to describe how his or her injury occurred. Remember, the abuser may be accompanying the child. Although photographs of injury can be invaluable, they are not the best method of documentation and should not be relied upon. Although the child’s caregiver may be able to provide information, that is also not the best way to document and the nurse needs to keep in mind that the caregiver could be the abuser. While the nurse will document what he or she observes, the best way to document the history and physical findings of a child suspected of being abused is to use the words the child has said to describe how his or her injury occurred.

Question 17 2 out of 2 points

In obtaining a review of systems on a “healthy” 7-year-old girl, what should the health care provider be sure to include?

Selected Answer:, a. Limitations r/t her involvement in sports activities Answers:, a. Limitations r/t her involvement in sports activities b. Last glaucoma examination c. Date of her last electrocardiogram d. Frequency of breast self-examinations

Response Feedback:, When completing a review of the cardiovascular system for a child the health care provider should ask whether there are any congenital heart defects, history of murmurs, or cyanosis as well as if any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age. The date of the last glaucoma examination, frequency of breast selfexaminations, and date of last electrocardiogram are not appropriate questions for a review of systems for a “healthy” 7-year-old.

Question 18 2 out of 2 points

During a mental status examination, the nurse wants to assess a patient’s affect. Which question the nurse should ask?

Selected Answer:, a. “How do you feel today?” Answers:, a. “How do you feel today?” b. “Would you please repeat the following words?” c. “Have these medications had any effect on your pain?” d. “Has this pain affected your ability to get dressed by yourself?”

Response Feedback:, Mood and affect should be judged by observing body language and facial expression and by directly asking, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should appropriately change with the topics. Options B, C, and D do not assess affect.

Question 19 2 out of 2 points

The nurse is conducting a class for new graduate nurses. While teaching the class, what should the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on?

Selected Answer:, d. A set of rules Answers:, a. Advice from supervisors

b. Intuition c. Articles in journals d. A set of rules

Response Feedback:, Novice nurses operate from a set of defined, structured rules to make decisions. It takes time, perhaps a few years, in similar clinical situations to achieve competency and it is functioning at the level of an expert practitioner when intuition is included in making clinical decisions. Intuition is included in decision making when functioning at the level of an expert practitioner. While information in journal articles and advice from supervisors may assist in making decisions, novice nurses do not typically base their decisions on them. It would also be important that if information from journal articles and advice from supervisors were used, that they were evidence based.

Question 20 2 out of 2 points

During change of shift report, the nurse hears that...