Which situation illustrates a screening assessment?
A: A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination.
B:A hospital sponsors a health fair at a local mall and provides cholesterol
B:A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons.
The nurse documents which information in the patient's history?
A: The patient's skin feels warm to the touch.
B: The patient is scratching his arm.
C: The patient's temperature is 100� F.
D: The patient complains of itching.
D: The patient complains of itching.
Which activity illustrates the concept of secondary prevention?
A: Annual mammogram
B: Nutrition classes on low-fat cooking
C: Education on living with diabetes mellitus
D: Cardiac rehabilitation after coronary artery bypass surgery
A: Annual mammogram
Which statement by the nurse demonstrates a patient-centered interview?
A: "I need to complete this questionnaire about your medical and family history."
B: "The hospital requires me to complete this assessment as soon as possible."
C: "Tell me about the
C: "Tell me about the symptoms you've been having.
The nurse suspects altered mental status for a patient. Which question is appropriate to ask when assessing mental status?
A: "Can you speak English?"
B: "Are you having marital problems?"
C: "Do you have abdominal pain?"
D: "Where are you?
D: "Where are you?
A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes?
A: Past health history
B: Present health status.
C: Reason for seeking care (chief co
B: Present health status.
The nurse is taking a patient's blood pressure and releases the valve 6-8 mm Hg/second. What will the reading likely be?
A: Accurate, the actual value
B: Higher than the actual value
C: Lower than the actual value
D: Unable to determine accuracy with avai
C: Lower than the actual value
When does a nurse choose to use skinfold calipers when collecting assessment data?
A: Calculating the patient's body mass index
B: Inspecting the patient's skin
C: Determining the amount of the patient's lean body tissue
D: Estimating the amount of the pa
D: Estimating the amount of the patient's body fat
A nurse suspects that a large skin lesion on the patient's forearm is a fungal infection. Which device does the nurse use to confirm his suspicion?
A: Pen light
B: Magnification device
C: Transilluminator
D: Wood lamp
D: Wood lamp
Which statement is correct regarding taking or interpreting axillary temperatures?
A: Axillary temperatures should not be used in patients less than 2 years of age.
B: Readings may be less accurate.
C: The thermometer is left in place for no more than 3 m
B: Readings may be less accurate.
Which nursing behaviors indicate culturally sensitive care?
A: Recognizing that there are different definitions of health and illness
B: Complying with the stated plan of treatment despite the patient's differing opinion
C: Asking the patients their dieta
C: Asking the patients their dietary preferences.
A patient has had chronic back pain for several years. On assessment, the nurse notes that the patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be in pain. When questioned, the patient rates the pain as a 6 on
B: Patients may not have the same objective responses to chronic pain because of compensation over time.
Which patient has pain caused by abnormal processing of sensory input from the peripheral nervous system?
A: The patient who has aching pain from muscle strain
B: The patient who has burning pain along the sciatic nerve
C: The patient who has cramping pai
B: The patient who has burning pain along the sciatic nerve
The nurse is performing a mental health assessment. Data collection for mental health assessment begins when the nurse
A: First sees the patient
B: Begins the physical exam
C: Obtains the family history
D: During the cultural assessment
A: First sees the patient
A nurse calculates a patient's body mass index (BMI) as 33. This measurement indicates which class of weight?
A: Overweight.
B: Obesity class I
C: Obesity class II
D: Obesity class III
B: Obesity class I
A male patient weighs 205 lb and his desired body weight (DBW) is 190 lb. How should the nurse counsel this patient about his weight?
A: He has mild obesity and needs to increase exercise and assess his diet for nutrients and calories.
B: He has moderate
C: He is within normal limits and need not be concerned at this time.
The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?
A: The measurement at 6 AM
B: The measurement at 12 PM
C: The measurement at 6 PM
D: The mea
A: The measurement at 6 AM
Nurses understand that a patient's diastolic pressure represents which physiologic function?
A: The pressure needed to open the aortic and pulmonic valves
B: The pressure in blood vessels when the ventricles contract
C: The pressure of the blood returning
D: The pressure in blood vessels when the ventricles are relaxed
Which technique used by the nurse encourages a patient to continue talking during an interview?
A: Laughing and smiling during conversation
B: Using phrases such as "Go on," and "Then?"
C: Repeating what the patient said, but using different words
D: Aski
B: Using phrases such as "Go on," and "Then?
For which patient is a focused health history most appropriate?
A: A new patient at the health clinic for an annual examination
B: A patient admitted to the hospital with vomiting and abdominal pain
C: A patient at the health care provider's office for a
B: A patient admitted to the hospital with vomiting and abdominal pain
A patient comes to the ambulatory surgery center for an elective procedure this morning. While giving the admission history, the patient states she is allergic to latex. What is the most appropriate response by the nurse at this time?
A: Removing all late
D: Questioning the patient about symptoms experienced in the past with latex
What part of the stethoscope do nurses use to auscultate the chest?
A: Press the bell firmly against the skin to hear sounds and vibrations.
B: The bell of the stethoscope is used to hear breath sounds.
C: The diaphragm of the stethoscope is used to hear
C: The diaphragm of the stethoscope is used to hear normal heart sounds.
How does the nurse detect a pulse when using a Doppler?
A: The pulsation is felt.
B: The pulsation is heard.
C: The pulse wave is seen on a screen.
D: The pulse wave is printed out on special paper.
B: The pulsation is heard.
How do nurses assess a patient's pain?
A: By assessing physiologic changes of the patient
B: By understanding the sensory experience related to the amount of tissue damage
C: By the patient's medical diagnosis or surgical procedure
D: By asking the patien
D: By asking the patient to rate the pain being experienced
A patient with a partial small bowel obstruction describes the pain as "cramping, off-and-on pain that spreads over my stomach." What type of pain is this patient experiencing?
A: Referred pain
B: Phantom pain
C: Somatic pain
D: Visceral pain
D: Visceral pain
The nurse notes in the patient's history that the patient has persistent, malignant pain. What is the meaning of this type of pain?
A: The pain has been present for at least 2 weeks.
B: The pain began after recent surgery and is associated with healing in
C: The pain has been present for 6 or more months.
When examining a patient, the nurse remembers to follow which principle of Standard Precautions?
A: Wear gloves throughout the entire examination of the patient.
B: Wear gloves when in contact with the patient's mucous membranes.
C: Wear gloves to reduce
B: Wear gloves when in contact with the patient's mucous membranes.
Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen saturation?
A: The chest over the patient's heart
B: Over the patient's abdominal aorta
C: Over the patient's radial pulse
D: Around the patient's index finge
D: Around the patient's index finger nail
A nurse is preparing to assess a patient's ability to detect vibrations. Which piece of equipment is appropriate for this assessment?
A: Reflex hammer
B: Tuning fork
C: Goniometer
D: Monofilament
B: Tuning fork
To test deep tendon reflexes, the nurse uses which instrument?
A: Goniometer
B: Calipers
C: Reflex hammer
D: Monofilament
C: Reflex hammer
The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min.
A: 16-month-old; 18
B: 6-year-old; 20
C: 14-year-old;26
D: 40-year-old; 10
B: 6-year-old; 20
A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid?
A: 1 L
B: 5 L
C: 11 L
D: 24 L
B: 5 L
Which data do nurses document under the heading of Personal and Psychosocial History? SELECT ALL THAT APPLY.
A: Walks for 45 minutes each day
B: Is allergic to milk and milk products
C: Is married and has two daughters whom is he close to
D: Smokes mariju
A: Walks for 45 minutes each day
C: Is married and has two daughters whom is he close to
D: Smokes marijuana once a week
Which action by the nurse results in the patient's blood pressure measurement being falsely high? SELECT ALL THAT APPLY.
A: Using a blood pressure cuff that is too narrow for the patient's upper arm
B: Deflating the blood pressure cuff too rapidly
C: Wrap
A: Using a blood pressure cuff that is too narrow for the patient's upper arm
C: Wrapping the blood pressure cuff too loosely
D: Reinflating the blood pressure cuff before it completely deflates
Which Korotkoff sounds are recorded for blood pressure measurement? SELECT ALL THAT APPLY.
A: First
B: Second.
C: Third
D: Fourth
E: Fifth
A: First
E: Fifth
Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake?
A: Food diary
B: 24 hour recall
C: Calorie count
D: Comprehensive diet history
B: 24 hour recall
Which of the following physical symptoms indicate clinical manifestations of fever?SELECT ALL THAT APPLY.
A: Increased pulse
B: increased appetite
C: increased thirst
D: malaise, weakness or aching muscles
E: increased respiratory rate
A: Increased pulse
C: increased thirst
D: malaise, weakness or aching muscles
E: increased respiratory rate
A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost _____ L from fluid loss.
3.6 L
(1 kg (2.2 lb) = 1 L; 187 - 179 = 8 lb weight loss divided by 2.2 = 3.6 L.)