TEOPIZ, MARK JOVAN JR.

BSN 4-A4
NURSING DISASTER

1. During the nursing assessment, which data represent information

concerning health beliefs?
a. Family role and relationship patterns
b. Educational level and financial status
c. Promotive, preventive, and restorative health practices
d. Use of prescribed and over-the-counter medications
RATIO: The health-beliefs assessment includes expectations of health care;
promotive, preventive, and restorative practices, such as breast self-
examination, testicular examination, and seat-belt use; and how the client
perceives illness.

2. Which assessment data should the nurse include when obtaining a

review of body systems
a. Brief statement about what brought the client to the health care provider
b. Client complaints of chest pain, dyspnea, or abdominal pain
c. Information about the client’s sexual performance and preference
d. The client’s name, address, age, and phone number
RATIO: Client complaints about chest pain, dyspnea, or abdominal pain are
considered part of the review of body systems. This potion of the
assessment elicits subjective information on the client's perceptions of major
body system functions, including cardiac, respiratory, and abdominal. The
client's name, address, age, and phone number are biographical data. A
brief statement about what brought the client to the health care provider is
the chief complaint.

3. A male client is admitted to the hospital with blunt chest trauma after
a motor vehicle accident. The first nursing
priority for this client would be to:
a. Assess the client’ s airway
b. Provide pain relief
c. Encourage deep breathing and coughing
d. Splint the chest wall with a pillow
RATIO: The first priority is to evaluate airway patency before assessing for
signs of obstruction, sternal retraction, stridor, or wheezing. Airway
management is always the nurse’s first priority. Pain management and
splinting are important for the client’s comfort, but would come after airway
assessment. Coughing and deep breathing may be contraindicated if the
client has internal bleeding and other injuries.

4. Nurse Kelly is acquiring information from a client in the emergency

department. Which is an example of biographic information that may
be obtained during a health history?
a. The chief complaint
b. Past health status
c. History immunizations
d. Location of an advance
RATIO: Biographic information may include name, address, gender, race,
occupation, and location of a living will or a durable power of attorney for
health care. The chief complaint, past health status, and history of
immunizations are part of assessing the client's health and illness patterns.

5. An anxious 24-year-old college student complains of tingling

sensations, palpitations, and chest tightness. Deep,
rapid breathing and carpal spasms are noted. What priority nursing action
should you take?
a. Notify the physician immediately.
b. Administer supplemental oxygen.
c. Have the student breathe into a paper bag.
d. Obtain an order for an anxiolytic medication.
RATIO: The client is hyperventilating secondary to anxiety, and breathing
into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging
slow breathing will help. Other treatments such as oxygen administration
and medication may be needed if other causes are identified. Focus:
Prioritization