The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
a.To provide an opportunity for interaction between the patient and the nurse
b.To provide a form for obtaining the patient's bio
d. To provide a database of subjective information about the patient's past and current health
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.
When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient:
a. Has a history of drug abuse and therefore is not reliable.
b. Provided consistent information and therefore is reliable.
c.
b. Provided consistent information and therefore is reliable.
A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.
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?
a. J.M. is a 59-year-old man seeking treatment for ulcerative col
d. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours.
The reason for seeking care is a brief spontaneous statement in the person's own words that describes the reason for the visit. It states one (possibly t
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?"
b. "We'll talk more about that later in the interview."
c. "What have you had to eat in the last 24
a. "Can you point to where it hurts?"
A final summary of any symptom the person has should include, along with seven other critical characteristics, "Location: specific." The person is asked to point to the location.
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 does your family react to your pain?"
b."The pain must be terrible. You probably pinched a n
d."How would you say the pain affects your ability to do your daily activities?"
The symptom of pain is difficult to quantify because of individual interpretation. With pain, adjectives should be avoided and the patient should be asked how the pain affect
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 usual childhood illnesses.
b.Patient states he was a "very healthy" child.
c.Patient states his sister had measle
d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the
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.P-6, B-4, (S)Ab-2
b.Grav 6, Term 4, (S)Ab-2,
b. Grav 6, Term 4, (S)Ab-2, Living 4
Obstetric history includes:
- the # of pregnancies (gravidity)
- number of deliveries in which the fetus reached term (term)
- number of preterm pregnancies (preterm)
- number of incomplete pregnancies (abortions)
- nu
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information?
a."Are you allergic to any other drugs?"
b."How often have you received penicillin?"
c."I'll write your allergy on your chart so you
D
Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a drug, this symptom should not be a side effect but a true aller
The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
a.Emphysema.
b.Head trauma.
c.Mental illness.
d.Fractured bones.
C
Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, sui
The review of systems provides the nurse with:
a.Physical findings related to each system.
b.Information regarding health promotion practices.
c.An opportunity to teach the patient medical terms.
d.Information necessary for the nurse to diagnose the patie
B
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 practice
Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin?
a.Skin appears dry.
b.No lesions are obvious.
c.Patient denies any color change.
d.Lesion is noted on the lateral aspect of the right ar
C
The history should be limited to patient statements or subjective data�factors that the person says were or were not present.
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
A
Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues.
Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
a."I broke my right leg in a car accident 2 weeks ago."
b."The pain is decreasing, but I still need to take acetaminophen."
c."I check the
D
Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues.
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."This has been a difficult year for you."
b."I don't know how anyone cou
C
Questions about coping and stress management include questions regarding the kinds of stresses in one's life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have be
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?
a.This information is necessary to determine the patient's reliability.
b. Alcohol can interact
B
Alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs
The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?
a."Maybe she is just teething."
b."I will check her ear for an ear infection."
c."Are you sure she is really having pain?"
d."Des
D
With a very young child, the parent is asked, "How do you know the child is in pain?" A young child pulling at his or her ears should alert parents to the child's ear pain. Statements about teething and questioning whether the child is really having pai
During an assessment of a patient's family history, the nurse constructs a genogram. Which statement best describes a genogram?
a.List of diseases present in a person's near relatives
b.Graphic family tree that uses symbols to depict the gender, relations
B
A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram.
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 birth weight
b.Age at which he crawled
c.Whether the child has had the measles
d.Child's reactions
D
How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not s
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
B
Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2006) recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years.
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.Last glaucoma examination.
b.Frequency of breast self-examinations.
c.Date of her last electrocardiogram.
d.Limita
D
When reviewing the cardiovascular system, the health care provider should ask whether 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.
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.Family history
b.Review of systems
c.Functional assessment
d.Reason for seeki
C
Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale
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.Obstetric history
b.Childhood illnesses
c.General health for the past 20 years
d. Current health promotion ac
D
It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age.
The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation?
a.The questions asked are identical for all ages.
b.The interviewer will start incorporating different questions for patients 70
C
The health history includes the same format as that described for the younger adult, as well as some additional questions. These additional questions address ways in which the activities of daily living may have been affected by the normal aging process
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."Can you tell me what they look like?"
b."Don't worry about it
D
The person may not know the drug name or purpose. When this occurs, ask the person or a family member to bring in the drug to be identified. The other responses would not help to identify the medications.
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."Do you wear glasses?"
b."Are you able to dress yourself?"
c."Do you have any thyroid problems?
B
Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.
The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
a.The functional assessment assesses how the individual is coping with life at home.
b.It determines how children are meeting deve
D
The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.
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?
a.Chest pain
b.Clammy skin
c.Serum potassium level at 4.2 mEq/L
d.Body temperature of 100� F
A
A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses.
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?
a."It is a sharp, burning pain in my stomach."
b."I also have the sweats and nausea when I feel this pain."
c."I think this
D
The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as "sharp and burning" reflects the character or quality of the pain; stating that the pain is "telling" the patient that something bad is
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 patient is an alcoholic.
b.The patient is annoyed at the questions.
c.The patient should be thoroughly examined for
D
The CAGE test is known as the "cut down, annoyed, guilty, and eye-opener" test. If a person answers "yes" to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment
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?
B
The "community" is assessed when the nurse asks whether a person is part of a religious or spiritual community or congregation. The other areas assessed are faith, influence, and addressing any religious or spiritual issues or concerns.
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."Please stay during the interview; you can ans
D
The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires.
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."Why did you come to the United States?"
b."When did you come to the United States and from what country?
B
Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions.
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."Did you have these headaches as a child?
A, C, D, E
The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; an
The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.
a."How much junk food does your child eat?"
b."How many teeth has he lost, an
B, C, E
Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergie
After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
A
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
C
Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective an
The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
A
Together with the patients record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patients record, laboratory studies, or data.
When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a co
C
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
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. Int
B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
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.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
A
Intuition is characterized by pattern recognition expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct.
The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP
C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the
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. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Indiv
D
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) (see Table 1-1).
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
C
Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1).
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
B
Clustering related cues helps the nurse see relationships among the data.
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions.
The nursing process is a sequential method of problem solving that nurses use and includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admi
D
The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
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
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d.
A
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems.
Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment
C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis.
Barriers to incorporating EBP include:
a. Nurses lack of research skills in evaluating the quality of research studies.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills.
A
As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not c
What step of the nursing process includes data collection by health history, physical examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
D
Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2).
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. Form a committee to co
D
Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate s
When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patien
D
Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and t
The nurse recognizes that the concept of prevention in describing health is essential because:
a. Disease can be prevented by treating the external environment.
b. The majority of deaths among Americans under age 65 years are not preventable.
c. Preventio
C
A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior.
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. Patients history of allergies.
b. Patients use of medications at home.
c. Last menstrua
D
Objective data are the patients record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data.
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 episo
C
The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens health care agency, visiting nurse agency, or community health agency. In
Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
a. Patient is admitted to a long-term care facility.
b. Patient has a sudden and severe shortness of breath.
c. Patient is admitted to the hospital
D
In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system.
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.
b. Ask her to read he
A
A follow-up data base is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation
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. Collect history in
B
The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation.
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:
a. Identify the cause of his illness.
b. Make accurate disease dia
D
The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care.
In the health promotion model, the focus of the health professional includes:
a. Changing the patients perceptions of disease.
b. Identifying biomedical model interventions.
c. Identifying negative health acts of the consumer.
d. Helping the consumer choo
D
In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle.
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individuals condition, and compare
C
Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individuals condition and compares the actual outcomes with expected outcomes (See Figure 1-2).
Which statement best describes a proficient nurse? A proficient nurse is one who:
a. Has little experience with a specified population and uses rules to guide performance.
b. Has an intuitive grasp of a clinical situation and quickly identifies the accura
D
The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how todays nursing actions can apply to the point the nur
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. H
A, C, E, F
Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels an
Put the following patient situations in order according to the level of priority.
a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
b. A teenager who was stung by a bee du
1. a = First-level priority problem
2. b = Second-level priority problem
3. c = Third-level priority problem
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 lobe
b. hyp
A C E F
Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e. g. wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and p
Plan the following patient situations in order according to the level of priority
a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with glucometer
b. A teenager who was stung by a bee durin
A, B, C
First level priority problems are immediate priorities, such as trouble breathing (ABC). Second-level priority problems are next in urgency, health can be addressed after more urgent health problems are addressed