NUR 2407 Health Assessment (GRADED A) answered test bank -Rasmussen College/ Download To Score An A

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NUR 2407 Health Assessment (GRADED A) answered test bank Chapter 01: Evidence-Based Assessment 1. After completing an initial assessment of a patient, the nurse has charted that his respiration... s are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. 2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be: a. Subjective. 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. 4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to: a. Validate the data by asking a coworker to listen to the breath sounds. 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. A set of rules. 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP emphasizes the use of best evidence with the clinician’s experience. 8. 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? a. Individual with shortness of breath and respiratory distress 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Abnormal laboratory values 10. Which critical thinking skill helps the nurse see relationships among the data? a. Clustering related cues 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a. Nursing 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep 14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Diagnostic hypothesis 1 15. Barriers to incorporating EBP include: a. Nurses’ lack of research skills in evaluating the quality of research studies. 16. What step of the nursing process includes data collection by health history, physical examination, and interview? a. Assessment 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Teach the nurses how to conduct electronic searches for research studies. 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Holistic health views the mind, body, and spirit as interdependent. 19. The nurse recognizes that the concept of prevention in describing health is essential because: a. Prevention places the emphasis on the link between health and personal behavior. 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. 2  5 cm scar on the right lower forearm. 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly 22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history? a. Patient is admitted to the hospital for surgery the following day. b. Patient in an outpatient clinic has cold and influenza-like symptoms. 23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure. 24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Simultaneously ask history questions while performing the examination and initiating life-saving measures. 25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: 2 a. Provide culturally sensitive and appropriate care. 26. In the health promotion model, the focus of the health professional includes: a. Helping the consumer choose a healthier lifestyle. 27. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Evaluate the individual’s condition, and compare actual outcomes with expected outcomes. 28. Which statement best describes a proficient nurse? A proficient nurse is one who: a. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient. 29. 30. 31. MULTIPLE RESPONSE 32. 1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Inspiratory wheezes noted in left lower lobes b. Nonproductive cough c. Patient reports dyspnea upon exertion d. Rate of respirations 16 breaths per minute 2. 3. MATCHING 4. Put the following patient situations in order according to the level of priority. a. .A teenager who was stung by a bee during a soccer match is having trouble breathing. b. An older adult with a urinary tract infection is also showing signs of confusion and agitation. c. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer 5. 6. 7. 8. Chapter 04: The Complete Health History 1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide a database of subjective information about the patient’s past and current health 2. When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient: a. Provided consistent information and therefore is reliable. 3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care? 3 a. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours. 4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response? a. “Can you point to where it hurts?” 5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement? a. “How would you say the pain affects your ability to do your daily activities?” 6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. 7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. Grav 6, Term 4, (S)Ab-2, Living 4 8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information? a. “Describe what happens to you when you take penicillin.” 9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Mental illness. 10. The review of systems provides the nurse with: a. Information regarding health promotion practices. 11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin? a. Patient denies any color change. 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. “Do you perform testicular self-examinations?” 13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. “I’m able to transfer myself from the wheelchair to the bed without help.” 14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. “What did you do to cope with the loss of both your husband and mother?” 15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? 4 a. Alcohol can interact with all medications and can make some diseases worse. 16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. “Describe what she is doing to indicate she is having pain.” 17. During an assessment of a patient’s family history, the nurse constructs a genogram. Which statement best describes a genogram? a. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members 18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child’s reactions to previous hospitalizations 19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. MMR vaccination needs to be repeated at 4 to 6 years of age. 20. In obtaining a review of systems on a “healthy” 7-year-old girl, the health care provider knows that it would be important to include the: a. Limitations related to her involvement in sports activities. 21. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Functional assessment 22. The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Current health promotion activities 23. The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. Questions that are reflective of the normal effects of aging are added. 24. A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. “Would you have a family member bring in your medications?” 25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. “Are you able to dress yourself?” 26. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. It helps determine how a person is managing day-to-day activities. 27. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? 5 a. Chest pain 28. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. “This pain happens every time I sit down to use the computer.” 29. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating? a. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment. 30. The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. “Are you a part of any religious or spiritual congregation?” 31. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?” 32. The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. “When did you come to the United States and from what country?” 33. MULTIPLE RESPONSE 1. The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. “Where is the headache pain?” b. “On a scale of 1 to 10, how bad is the pain?” c. “How often do the headaches occur?” d. “What makes the headaches feel better?” 2. The nurse is conducting a developmental history on a 5-year-old child. Which questions a. “How many teeth has he lost, and when did he lose them?” b. “Is he able to tie his shoelaces?” c. “Can he tell time?” 34. 35. 36. Chapter 05: Mental Status Assessment 1. During an examination, the nurse can assess mental status by which activity? a. Observing the patient and inferring health or dysfunction 2. The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a. All aspects of mental status in children are interdependent. 3. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: 6 a. May take a little longer to respond, but his general knowledge and abilities should not have declined. 4. When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: a. Sensory-perceptive abilities 5. The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. Gathering mental status information during the health history interview is usually sufficient. 6. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action? a. Perform a complete mental status examination. 7. The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? a. “I never did too good in school.” 8. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse’s best approach regarding this examination is to: a. Plan to defer the rest of the mental status examination. 9. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: a. More information should be gathered to decide whether her dress is appropriate. 10. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: a. Will be oriented to place and person, but the patient may not be certain of the date. 11. During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question? a. “How do you feel today?” 12. The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a. Give him the Four Unrelated Words Test. 13. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not four unrelated words . a. Recall; after a 30-minute delay 7 14. During a mental status assessment, which question by the nurse would best assess a person’s judgment? a. “Tell me what you plan to do once you are discharged from the hospital.” 15. Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Older adult man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun 16. The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl’s mental status? a. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare. 17. The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. “I know my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010.” 18. The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant’s parents that the Denver II: a. Is a screening instrument designed to detect children who are slow in development. 19. A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient’s level of consciousness would be: a. Lethargic 20. A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best description of this patient’s problem? a. Wernicke’s aphasia 21. A patient repeatedly seems to have difficulty coming up with a word. He says, “I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.” The nurse will note on his chart that he is using or experiencing: a. Circumlocution 22. During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? a. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.” 23. A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: a. Has a snake phobia. 8 24. A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: a. Inappropriate affect 25. During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. 26. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient’s: a. Level of consciousness and cognitive abilities 27. A patient states, “I feel so sad all of the time. I can’t feel happy even doing things I used to like to do.” He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? a. “How long have you been feeling this way?” 28. A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? a. “Are you having any disturbing dreams?” 29. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status functioning is inferred through the assessment of an individual’s behaviors. 30. 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 to assess attention span? a. “Pick up the pencil in your left hand, move it to your right hand, and place it on the table.” 31. The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? a. “Please point to articles in the room and parts of the body as I name them.” 32. A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse’s best response in this situation? a. “Are you feeling so hopeless that you feel like hurting yourself now?” 33. The nurse is providing instructions to newly hired graduates for the mini– mental state examination (MMSE). Which statement best describes this examination? 9 a. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. 34. The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global 35. A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” The nurse documents this as an illustration of: a. Clanging 36. During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a. Compulsive disorder 37. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a. Cognitive impairment 38. During morning rounds, the nurse asks a patient, “How are you today?” The patient responds, “You today, you today, you today!” and mumbles the words. This speech pattern is an example of: a. Echolalia 39. 40. MULTIPLE RESPONSE 1. The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply a. Develops over a short period. b. Person is exhibiting memory impairment or deficits. c. Occurs as a result of a medical condition, such as systemic infection. 10 2. 3. 4. 5. 6. 7. 8. Chapter 08: Assessment Techniques and Safety in the Clinical Setting 1. When performing a physical assessment, the first technique the nurse will always use is: 9. Inspection. 2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: 10. Takes time and reveals a surprising amount of information. 3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature? 11. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. 4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? 12. Palpation 5. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed? 13. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. 6. The nurse would use bimanual palpation technique in which situation? 14. Palpating the kidneys and uterus 7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a. Density 8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area 9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. 10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Increase the amount of strength used when attempting to percuss over the abdomen. 11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should: a. Consider this finding as normal for a child this age, and proceed with the examination. 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Bilaterally percuss the thorax, noting any differences in percussion tones. 13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Although the stethoscope does not magnify sound, it does block out extraneous room noise. 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. 15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a. Check the temperature of the room, and offer blankets to the patient if he or she feels cold. 16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation 17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Directs light into the ear canal and onto the tympanic membrane. 18. An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Rotating the lens selector dial to bring the object into focus 19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Use a Doppler device to check for pulsations over the area. 20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a. Organizes the assessment to ensure that the patient does not change positions too often. 21. A man is at the clinic for a physical examination. He states that he is “very anxious” about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. 22. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Hands are washed before and after every physical patient encounter. 23. The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing hands, putting on gloves, and continuing with the examination of the ulceration 24. During the examination, offering some brief teaching about the patient’s body or the examiner’s findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. “Your pulse is 80 beats per minute, which is within the normal range.” 25. The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner to build rapport and to increase the patient’s confidence in him or her. 26. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a. At the end of the examination 27. When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. 28. A 6-month-old infant has been brought to the well-child clinic for a check- up. She is currently sleeping. What should the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. 29. A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a. object such as a toy or blanket during the examination. 30. The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate? a. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available 31. With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Preschool child 32. The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Give the child feedback and reassurance during the examination. 33. When examining a 16-year-old male teenager, the nurse should: a. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. 34. When examining an older adult, the nurse should use which technique? a. Arrange the sequence of the examination to allow as few position changes as possible. 35. The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wash hands before and after contact with each patient. 36. Which of these statements is true regarding the use of Standard Precautions in the health care setting? a. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. 37. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved. 38. When examining an infant, the nurse should examine which area first? a. Abdomen 39. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Bell of the stethoscope 40. During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates: a. Air-filled areas. 41. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The nurse should keep in mind that a child at this age will have a sense of modesty. 42. During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. The nurse should: a. Ask another nurse to double check the finding. 15. 16. MULTIPLE RESPONSE 1. The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply. a. Warm the hands first before touching the patient. b. Start with light palpation to detect surface characteristics. c. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps. d. Identify any tender areas, and palpate them last. 17. 18. 19. 20. 21. 22. Chapter 09: General Survey, Measurement, Vital Signs 1. The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patient’s body stature and nutritional status 2. When measuring a patient’s weight, the nurse is aware of which of these guidelines? a. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. 3. A patient’s weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? a. Prehypertension 4. During an examination of a child, the nurse considers that physical growth is the best index of a child’s: a. General health. 5. A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would: a. Consider these findings normal for a 1-month-old infant. 6. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? a. Presence of kyphosis and flexion in the knees and hips 7. The nurse should measure rectal temperatures in which of these patients? a. Comatose adult 8. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct? a. Measuring the chest circumference at the nipple line with a tape measure 9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: a. Rapid measurement is useful for uncooperative younger children. 10. When assessing an older adult, which vital sign changes occur with aging? a. Widened pulse pressure 11. The nurse is examining a patient who is complaining of “feeling cold.” Which is a mechanism of heat loss in the body? a. Radiation 12. When measuring a patient’s body temperature, the nurse keeps in mind that body temperature is influenced by: a. Diurnal cycle. 13. When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult’s body temperature? a. The body temperature of the older adult is lower than that of a younger adult. 14. A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an “unexplained” weight loss of 10 pounds over the last 6 weeks. The nurse knows that: a. Unexplained weight loss often accompanies short-term illnesses. 15. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: a. Recognize that a tripod position is often used when a patient is having respiratory difficulties. 16. Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? a. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. 17. The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? a. The risk of cross-contamination is reduced, compared with the rectal route. 18. To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip thermometer. 19. Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a. 1 minute, if the rhythm is irregular. 20. When assessing a patient’s pulse, the nurse should also notice which of these characteristics? a. Force 21. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse’s next action would be to: a. Consider this finding normal in children and young adults. 22. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: a. Is a reflection of the heart’s stroke volume. 23. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature–36° C; pulse–48 beats per minute; respirations–14 breaths per minute; blood pressure–104/68 mm Hg. Which statement is true concerning these results? a. These are normal vital signs for a healthy, athletic adult. 24. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child’s respirations? a. Respirations should be counted for 1 full minute, noticing rate and rhythm. 25. A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” The nurse’s best reply is: a. “The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.” 26. While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as , help determine blood pressure. a. Peripheral vascular resistance 27. A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: a. The blood pressure of a Black adult is usually higher than that of a White adult of the same age. 28. The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: a. Yield a falsely high blood pressure. 29. A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: a. Allow 5 minutes for him to relax and rest before checking his vital signs. 30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: a. Detect the presence of an auscultatory gap. 31. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? a. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. 32. The nurse has collected the following information on a patient: palpated blood pressure–180 mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse– 60 beats per minute; radial pulse–70 beats per minute. What is the patient’s pulse pressure? a. 70 33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure? a. 200/92 34. A patient is seen in the clinic for complaints of “fainting episodes that started last week.” How should the nurse proceed with the examination? a. His blood pressure is recorded in the lying, sitting, and standing positions. 35. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings? a. The change in blood pressure readings is called orthostatic hypotension. 36. The nurse is helping another nurse to take a blood pressure reading on a patient’s thigh. Which action is correct regarding thigh pressure? a. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. 37. The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? a. Respirations are measured; then pulse and temperature. 38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant’s vital signs? a. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia. 39. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? a. An increased respiratory rate and a shallower inspiratory phase are expected findings. 40. In a patient with acromegaly, the nurse will expect to discover which assessment findings? a. Overgrowth of bone in the face, head, hands, and feet 41. The nurse is performing a general survey of a patient. Which finding is considered normal? a. Arm span (fingertip to fingertip) equals the patient’s height. 42. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children? a. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children. 43. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap? a. Systolic blood pressure may be falsely low. 44. When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement? a. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle. 45. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? a. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions. 46. Which of these specific measurements is the best index of a child’s general health? a. Height and weight 47. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have? a. Hypopituitary dwarfism 48. The nurse is counting an infant’s respirations. Which technique is correct? a. Watching the abdomen for movement 49. When checking for proper blood pressure cuff size, which guideline is correct? a. The width of the rubber bladder should equal 40% of the arm circumference. 50. During an examination, the nurse notices that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition? a. Cushing syndrome 23. 24. 25. 26. 27. MULTIPLE RESPONSE 1. While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply. a. The person supports his or her own arm during the blood pressure reading. b. The blood pressure cuff is too narrow for the extremity. c. The cuff is loosely wrapped around the arm. d. The person is sitting with his or her legs crossed. 28. 29. SHORT ANSWER 2. What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute? 158-96=62 30. 31. 32. Chapter 10: Pain Assessment: The Fifth Vital Sign 1. When evaluating a patient’s pain, the nurse knows that an example of acute pain would be: a. Kidney stones. 2. Which statement indicates that the nurse understands the pain experienced by an older adult? a. “Pain indicates a pathologic condition or an injury and is not a normal process of aging.” 3. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, “It hurts so bad.” Which pain assessment tool would be the best choice when assessing this child’s pain? a. Faces Pain Scale—Revised (FPS-R) 4. A patient states that the pain medication is “not working” and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? a. Increased blood pressure and pulse 5. A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the: a. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain. 6. The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the: a. Subjective report. 7. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: a. Has experienced chronic pain for years and has adapted to it. 8. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? a. Neuropathic 9. When assessing the quality of a patient’s pain, the nurse should ask which question? a. “What does your pain feel like?” 10. When assessing a patient’s pain, the nurse knows that an example of visceral pain would be: a. Cholecystitis. 11. The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? a. Perception 12. When assessing the intensity of a patient’s pain, which question by the nurse is appropriate? a. “How much pain do you have now?” 13. A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? a. Administering pain medication and then proceeding with the assessment 14. The nurse knows that which statement is true regarding the pain experienced by infants? a. A procedure that induces pain in adults will also induce pain in the infant. 15. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: a. Deep somatic. 33. 34. MULTIPLE RESPONSE 1. During assessment of a patient’s pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. a. Sleeping b. Rubbing 2. During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. a. Assess the patient’s breathing independent of vocalization. b. Note whether the patient is calling out, groaning, or crying. c. Observe the patient’s body language for pacing and agitation. 35. 36. 37. 38. Chapter 11: Nutritional Assessment 1. The nurse recognizes which of these persons is at greatest risk for undernutrition? a. 5-month-old infant 2. When assessing a patient’s nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that: a. Provide for daily body requirements and support increased metabolic demands. 3. The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group? a. Maintaining adequate fat and caloric intake is important for a child in this age group. 4. A pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which information is appropriate for the nurse to share with her? a. Breast milk provides the nutrients necessary for growth, as well as natural immunity. 5. A mother and her 13-year-old daughter express their concern related to the daughter’s recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them? a. Snacks should be high in protein, iron, and calcium. 6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find? a. Osteomalacia (softening of the bones) 7. For the first time, the nurse is seeing a patient who has no history of nutrition- related problems. The initial nutritional screening should include which activity? a. Measurement of weight and weight history 8. A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information? a. Food-frequency questionnaire 9. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? a. Absorption of nutrients may be impaired. 10. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? a. Certain drugs can affect the metabolism of nutrients. 11. A patient tells the nurse that his food simply does not have any taste anymore. The nurse’s best response would be: a. “When did you first notice this change?” 12. The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that she is “so fat.” Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse’s appropriate response would be: a. “How much do you think you should weigh?” 13. The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended? a. Finger foods and nutritious snacks that cannot cause choking 14. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult? a. Living alone on a fixed income 15. When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a. Height and weight. 16. If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the woman’s weight? a. Obese 17. How should the nurse perform a triceps skinfold assessment? a. After applying the calipers, the nurse waits 3 seconds before taking a reading. After repeating the procedure three times, an average is recorded. 18. In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: a. Height and weight. 19. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk? a. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches 20. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? a. Provide information regarding a diet low in saturated fat. 21. In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? a. Inadequate nutrient food intake 22. A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find? a. Decreased serum albumin 23. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: a. Slowed gastrointestinal motility. 24. Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? a. Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass 25. A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information? a. Having the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day 26. The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate? a. Dual-energy x-ray absorptiometry (DEXA) 27. Which of these conditions is due to an inadequate intake of both protein and calories? a. Marasmus 28. During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin? a. Riboflavin 29. A 50-year-old patient has been brought to the emergency department after a housemate found that the patient could not get out of bed alone. He has lived in a group home for years but for several months has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia, which is a deficiency of: a. Vitamin D and calcium. 30. An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient’s gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition? a. Vitamin C deficiency 31. The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient’s usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient’s ideal body weight and concludes that the patient is: a. Experiencing moderate malnutrition. 39. 40. 41. MULTIPLE RESPONSE 1. The nurse is assessing a patient who is obese for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. a. Fasting plasma glucose level greater than or equal to 110 mg/dL b. Blood pressure reading of 140/90 mm Hg 42. 43. 44. SHORT ANSWER 1. A patient has been unable to eat solid food for 2 weeks and is in the clinic today complaining of weakness, tiredness, and hair loss. The patient states that her usual weight is 175 pounds, but today she weighs 161 pounds. What is her recent weight change percentage? To calculate recent weight change percentage, use this formula: 45. Usual weight – current weight  100 46. usual weight 47. 48. 175 – 161 = 14 pounds 49. 14 ÷ 175 = 0.08 50. 0.08  100 = 8% 51. 52. [Show More]

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