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Nur Health Nclex Assesment As Best Exam Solution
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University:
Chamberlain University -
Course:
NR-599 | Nursing Informatics For Advanced Practice Academic year:
2025
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Pages:
65
Author:
zena ahmad
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Chapter 01: Evidence-Based Assessment
After completing an initial assessment of a patient, the nurse has
charted that hisrespirations are eupneic and his pulse is 58 beats
per minute. These types of datawould be:
a. Objective.
A patient tells the nurse that he is very nervous, is nauseated,
and “feels hot.”These types of data would be:
a. Subjective.
The patient’s record, laboratory studies, objective data, and
subjective datacombine to form the:
a. Data base.
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 collectin this setting?
a. A follow-up data base to evaluate changes at appropriate
intervals
b. An episodic data base because of the continuing,
complex medicalproblems of this patient
c. A complete health data base because of the nurse’s
primary responsibilityfor monitoring the patient’s health
d. An emergency data base because of the need to collect
information andmake accurate diagnoses rapidly
Which situation is most appropriate during which the nurse
performs a focused orproblem-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.
A patient is at the clinic to have her blood pressure checked. She
has been comingto 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.
A patient is brought by ambulance to the emergency
department with multiple traumas received in an automobile
accident. He is alert and cooperative, but hisinjuries are quite
severe. How would the nurse proceed with data collection?
a. Simultaneously ask history questions while performing
the examinationand initiating life-saving measures.
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 healthassessment is important to:
2
a. Provide culturally sensitive and appropriate care.
In the health promotion model, the focus of the health professional
includes:
a. Helping the consumer choose a healthier lifestyle.
The nurse has implemented several planned interventions to
address the nursingdiagnosis of acute pain. Which would be the
next appropriate action?
a. Evaluate the individual’s condition, and compare actual
outcomes withexpected outcomes.
Which statement best describes a proficient nurse? A proficient NUR HEALTH NCLEX ASSESMENT ANSWERED TEST BANK Q &
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nurse is one who:
a. Understands a patient situation as a whole rather than a
list of tasks andrecognizes the long-term goals for the
patient.
When listening to a patient’s breath sounds, the nurse is unsure
of a sound that isheard. The nurse’s next action should be to:
a. Validate the data by asking a coworker to listen to the breath
sounds.
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 backgroundof skills and experience from
which to draw, are more likely to make their decisions using:
a. A set of rules.
Expert nurses learn to attend to a pattern of assessment data
and act withoutconsciously labeling it. These responses are
referred to as:
a. Intuition.
The nurse is reviewing information about evidence-based
practice (EBP). Whichstatement best reflects EBP?
a. EBP emphasizes the use of best evidence with the clinician’s
experience.
The nursing process is a sequential method of problem solving
that nurses use andincludes which steps?
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a. Assessment, diagnosis, outcome identification, planning,
implementation,and evaluation
A newly admitted patient is in acute pain, has not been sleeping
well lately, and ishaving difficulty breathing. How should the
nurse prioritize these problems?
a. Breathing, pain, and sleep
Which of these would be formulated by a nurse using diagnostic
reasoning?
a. Diagnostic hypothesis
1
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Barriers to incorporating EBP include:
a. Nurses’ lack of research skills in evaluating the quality of
research studies.
What step of the nursing process includes data collection by
health history,physical examination, and interview?
a. Assessment
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.
When reviewing the concepts of health, the nurse recalls that
the components ofholistic health include which of these?
a. Holistic health views the mind, body, and spirit as
interdependent.
The nurse recognizes that the concept of prevention in
describing health isessential because:
a. Prevention places the emphasis on the link between
health and personalbehavior.
The nurse is performing a physical assessment on a newly
admitted patient. Anexample of objective information obtained
during the physical assessment includes the:
a. 2
5 cm scar on the right lower forearm.
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The nurse is conducting a class on priority setting for a group
of new graduatenurses. Which is an example of a first-level
priority problem?
a. Individual with shortness of breath and respiratory distress
When considering priority setting of problems, the nurse
keeps in mind thatsecond-level priority problems include
which of these aspects?
a. Abnormal laboratory values
Which critical thinking skill helps the nurse see relationships
among the data?
a. Clustering related cues
The nurse knows that developing appropriate nursing
interventions for a patientrelies on the appropriateness of the
diagnosis.
a. Nursing
MULTIPLE
RESPONSE32.
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 togetherduring data analysis? Select all
that apply.
a. Inspiratory wheezes noted in left lower lobes
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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 havingtrouble breathing.
b. An older adult with a urinary tract infection is also
showing signs ofconfusion and agitation.
c. A patient newly diagnosed with type 2 diabetes mellitus
does not knowhow to check his own blood glucose levels
with a glucometer
8. Chapter 04: The Complete Health History
1. The nurse is preparing to conduct a health history.
Which of thesestatements best describes the purpose
of a health history?
a. To provide a database of subjective information
about the patient’spast and current health
2. When the nurse is evaluating the reliability of a patient’s
responses, whichof these statements would be correct? The
patient:
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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 bestdocument his reason for
seeking care?
3
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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’sstatement?
a.
“How would you say the pain affects your ability to
do your dailyactivities?”
6. In recording the childhood illnesses of a patient who
denies having hadany, which note by the nurse would be
most accurate?
a. Patient denies measles, mumps, rubella, chickenpox,
pertussis, andstrep throat.
7. A female patient tells the nurse that she has had six
pregnancies, with fourlive 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 thenurse’s best response to this
information?
a.
“Describe what happens to you when you take
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penicillin.”
9. The nurse is taking a family history. Important diseases or
problems aboutwhich the patient should be specifically
asked include:
a. Mental illness.
The review of systems provides the nurse with:
10.
a. Information regarding health promotion practices.
Which of these statements represents subjective
11.
data the nurse obtainedfrom the patient regarding the
patient’s skin?
a. Patient denies any color change.
The nurse is obtaining a history from a 30-year-old
12.
male patient and is concerned about health promotion
activities. Which of these questions would be appropriate
to use to assess health promotion activities for thispatient?
a. “Do you perform testicular self-examinations?”
Which of these responses might the nurse expect
13.
during a functionalassessment of a patient whose leg is
in a cast?
a.
“I’m able to transfer myself from the
wheelchair to the bedwithout 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
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appropriate?
a.
“What did you do to cope with the loss of both your
husband andmother?”
15.
In response to a question regarding the use of
alcohol, a patient asks thenurse why the nurse needs to
know. What is the reason for needing thisinformation?
4
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a. Alcohol can interact with all medications and can
make somediseases worse.
The mother of a 16-month-old toddler tells the nurse
16.
that her daughter hasan 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 agenogram. 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 tonsilsremoved. 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 measlesmumps-rubella (MMR) vaccination was at 15months of
age. What recommendation should the nurse make?
a. MMR vaccination needs to be repeated at 4 to 6 years
of age.
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In obtaining a review of systems on a “healthy” 7-
20.
year-old girl, the healthcare provider knows that it would
be important to include the:
a. Limitations related to her involvement in sports
activities.
When the nurse asks for a description of who lives
21.
with a child, the method of discipline, and the support
system of the child, what part of theassessment is being
performed?
a. Functional assessment
The nurse is obtaining a health history on an 87-
22.
year-old woman. Whichof the following areas of
questioning would be most useful at this time?
a. Current health promotion activities
The nurse is performing a review of systems on a
23.
76-year-old patient.Which of these statements is correct
for this situation?
a. Questions that are reflective of the normal effects
of aging areadded.
A 90-year-old patient tells the nurse that he cannot
24.
remember the names ofthe 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
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medications?”
The nurse is performing a functional assessment on an
25.
82-year-old patientwho recently had a stroke. Which of
these questions would be most important to ask?
a.
26.
“Are you able to dress yourself?”
The nurse is preparing to do a functional
assessment. Which statementbest 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 anexample of a
symptom?
5
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a. Chest pain
A patient is describing his symptoms to the
28.
nurse. Which of thesestatements reflects a
description of the setting of his symptoms?
a.
“This pain happens every time I sit down to use the
computer.”
During an assessment, the nurse uses the CAGE test.
29.
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 morethorough substance abuse
assessment.
The nurse is incorporating a person’s spiritual
30.
values into the health history. Which of these questions
illustrates the “community” portion ofthe 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?”
The nurse is preparing to complete a health
31.
assessment on a 16-year-old girl whose parents have
brought her to the clinic. Which instruction wouldbe
appropriate for the parents before the interview begins?
a.
“While I interview your daughter, will you step out
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to the waitingroom and complete these family health
history questionnaires?”
The nurse is assessing a new patient who has recently
32.
immigrated to theUnited States. Which question is
appropriate to add to the health history?
a.
“When did you come to the United States
and from whatcountry?”
33.MULTIPLE RESPONSE
1. The nurse is assessing a patient’s headache pain. Which
questions reflect oneor 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. Whichquestions
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
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which activity?
a. Observing the patient and inferring health or dysfunction
2. The nurse is assessing the mental status of a child. Which
statement aboutchildren 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 mentalstatus portion of the assessment, the
nurse expects that this patient:
6
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a. May take a little longer to respond, but his general
knowledge and abilitiesshould not have declined.
4. When assessing aging adults, the nurse knows that one of the
first things thatshould 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. Whichstatement is true regarding the
mental status examination?
a. Gathering mental status information during the health
history interview isusually 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 bestcourse of action?
a. Perform a complete mental status examination.
7. The nurse is conducting a patient interview. Which
statement made by thepatient 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 dysarthricspeech and is lethargic. The
nurse’s best approach regarding this examinationis to:
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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. Sheis wearing black combat boots and a black
lace nightgown over the top of herother 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 isappropriate.
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 ofthe date.
11. During a mental status examination, the nurse wants to
assess a patient’saffect. 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 forthe nurse to do this would be to:
a. Give him the Four Unrelated Words Test.
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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
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14. During a mental status assessment, which question by the
nurse would bestassess 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 asuicide attempt?
a. Older adult man who tells the nurse that he is going to
“join his wife inheaven” tomorrow and plans to use a
gun
16. The nurse is performing a mental status assessment on a 5year-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 ofkids her own age while in daycare.
17. The nurse is assessing orientation in a 79-year-old patient.
Which of theseresponses 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 tellyou 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 12month-old infant during a routine well-child visit. The nurse
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should tell the infant’s parents thatthe Denver II:
a. Is a screening instrument designed to detect children
who are slow indevelopment.
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 duringthe conversation. The best
description of this patient’s level of consciousnesswould 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 ofideas. 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 ababy’s bottom.”
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23. A patient describes feeling an unreasonable, irrational fear
of snakes. His fearis 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
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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. Thisbehavior
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 shouldfirst
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 doingthings I used to like to do.” He also states
that he is tired, sleeps poorly, andhas 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 tothe clinic today for a follow-up assessment.
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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 anindividual’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 statementswould 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, andplace 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 ismost 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 namethem.”
32. A 30-year-old female patient is describing feelings of
hopelessness and depression. She has attempted selfmutilation and has a history of suicide attempts. She
describes difficulty sleeping at night and has lost 10 pounds
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inthe 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
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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 nursedocuments 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 withthe 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:
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a. Echolalia
39.
40.MULTIPLE RESPONSE
1. The nurse is assessing a patient who is admitted with possible
delirium. Whichof 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.
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10
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2.
3.
4.
5.
6.
7.
8. Chapter 08: Assessment Techniques and Safety in the
ClinicalSetting
When performing a physical assessment, the first
technique the nurse willalways use is:
9.
Inspection.
The nurse is preparing to perform a physical assessment.
Which statementis true about the physical assessment? The
inspection phase:
10.
Takes time and reveals a surprising amount of
information.
The nurse is assessing a patient’s skin during an office visit.
What part ofthe 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 thissurface than on the palms.
Which of these techniques uses the sense of touch to assess
texture, temperature, moisture, and swelling when the
nurse is assessing a patient?
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12.
Palpation
The nurse is preparing to assess a patient’s abdomen by
palpation. Howshould the nurse proceed?
13.
The assessment begins with light palpation to
detect surfacecharacteristics and to accustom the
patient to being touched.
The nurse would use bimanual palpation technique in which
situation?
14.
Palpating the kidneys and uterus
The nurse is preparing to percuss the abdomen of a patient.
The purpose ofthe percussion is to assess the
of the
underlying tissue.
a. Density
When examining an older adult, the nurse should use which
technique?
a. Arrange the sequence of the examination to allow as
few positionchanges as possible.
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The most important step that the nurse can take
to prevent thetransmission of microorganisms in
the hospital setting is to:
a. Wash hands before and after contact with each patient.
Which of these statements is true regarding the
use of StandardPrecautions in the health care
setting?
a. Standard Precautions are intended for use
with all patients,regardless of their risk or
presumed infection status.
The nurse is preparing to assess a hospitalized patient who
is experiencingsignificant shortness of breath. How should
the nurse proceed with the assessment?
a. Body areas appropriate to the problem should be
examined andthen the assessment completed after
the problem has resolved.
When examining an infant, the nurse should examine which
area first?
a. Abdomen
While auscultating heart sounds, the nurse hears a
murmur. Which ofthese instruments should be used to
assess this murmur?
a. Bell of the stethoscope
During an examination of a patient’s abdomen, the nurse
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notes that the abdomen is rounded and firm to the touch.
During percussion, the nursenotes a drumlike quality of
the sounds across the quadrants. This type ofsound
indicates:
a. Air-filled areas.
The nurse is preparing to examine a 6-year-old child. Which
action is mostappropriate?
a. The nurse should keep in mind that a child at this
age will have asense of modesty.
During auscultation of a patient’s heart sounds, the
nurse hears anunfamiliar sound. The nurse should:
a. Ask another nurse to double check the finding.
.
The nurse is reviewing percussion techniques with a
newly graduatednurse. Which technique, if used by the
new nurse, indicates that morereview is needed?
a. Percussing once over each area
When percussing over the liver of a patient, the nurse
notices a dull sound.The nurse should:
a. Consider this a normal finding.
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?
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a. Increase
the amount of strength used when
attempting to percussover the abdomen.
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 proceedwith the examination.
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A patient has suddenly developed shortness of breath and
appears to be insignificant respiratory distress. After
calling the physician and placing thepatient 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 percussiontones.
The nurse is teaching a class on basic assessment skills.
Which of thesestatements is true regarding the
stethoscope and its use?
a. Although the stethoscope does not magnify sound,
it does blockout extraneous room noise.
The nurse is preparing to use a stethoscope for
auscultation. Whichstatement is true regarding the
diaphragm of the stethoscope? The diaphragm:
a. Is used to listen for high-pitched sounds.
Before auscultating the abdomen for the presence of
bowel sounds on apatient, the nurse should:
a. Check the temperature of the room, and offer
blankets to thepatient if he or she feels cold.
The nurse will use which technique of assessment to
determine thepresence of crepitus, swelling, and
pulsations?
a. Palpation
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The nurse is preparing to use an otoscope for an
examination. Whichstatement is true regarding the
otoscope? The otoscope:
a. Directs light into the ear canal and onto the tympanic
membrane.
An examiner is using an ophthalmoscope to examine a
patient’s eyes. Thepatient 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
The nurse is unable to palpate the right radial pulse on a
patient. The bestaction would be to:
a. Use a Doppler device to check for pulsations over the
area.
The nurse is preparing to perform a physical
assessment. The correctaction by the nurse is reflected
by which statement? The nurse:
a. Organizes the assessment to ensure that the patient
does not changepositions too often.
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?
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a. Appear unhurried and confident when examining him.
When performing a physical examination, safety must be
considered to protect the examiner and the patient against
the spread of infection. Whichof 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 patientencounter.
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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
continuing
hands, putting on gloves, and
with
the examination
of
the
ulceration
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 normalrange.”
The nurse keeps in mind that the most important
reason to share information and to offer brief teaching
while performing the physicalexamination is to help the:
a. Examiner to build rapport and to increase the
patient’s confidencein him or her.
The nurse is examining an infant and prepares to elicit the
Moro reflex atwhich time during the examination?
a. At the end of the examination
When preparing to perform a physical examination on an
infant, the nurseshould:
a. Have the parent remove all clothing except the diaper
on a boy.
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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.
A 2-year-old child has been brought to the clinic for a wellchild checkup.The best way for the nurse to begin the
assessment is to:
a. object such as a toy or blanket during the examination.
The nurse is examining a 2-year-old child and asks, “May
I listen to yourheart now?” Which critique of the nurse’s
technique is most accurate?
a. Children at this age like to say, “No.” The
examiner should notoffer a choice when no choice
is available
With which of these patients would it be most appropriate
for the nurse touse games during the assessment, such as
having the patient “blow out” the light on the penlight?
a. Preschool child
The nurse is preparing to examine a 4-year-old child.
Which action isappropriate for this age group?
a. Give the child feedback and reassurance during the
examination.
When examining a 16-year-old male teenager, the nurse
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should:
a. Provide feedback that his body is developing
normally, and discussthe wide variation among
teenagers on the rate of growth and development.
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, andpresence of lumps.
d. Identify any tender areas, and palpate them last.
22. Chapter 09: General Survey, Measurement, Vital Signs
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 nursewould:
a. Consider these findings normal for a 1-month-old infant.
The nurse is assessing an 80-year-old male patient. Which
assessment findingswould be considered normal?
a. Presence of kyphosis and flexion in the knees and hips
The nurse should measure rectal temperatures in which of these
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patients?
a. Comatose adult
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
The nurse knows that one advantage of the tympanic
membrane thermometer(TMT) is that:
a. Rapid measurement is useful for uncooperative younger
children.
When assessing an older adult, which vital sign changes occur with
aging?
a. Widened pulse pressure
The nurse is examining a patient who is complaining of “feeling
cold.” Which is amechanism of heat loss in the body?
a. Radiation
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The nurse is performing a general survey. Which action is a
component of thegeneral survey?
a. Observing the patient’s body stature and nutritional status
When measuring a patient’s weight, the nurse is aware of
which of theseguidelines?
a. Attempts should be made to weigh the patient at
approximately the sametime of day, if a sequence of
weights is necessary.
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
During an examination of a child, the nurse considers that
physical growth is thebest index of a child’s:
a. General health.
When measuring a patient’s body temperature, the nurse keeps
in mind that bodytemperature is influenced by:
a. Diurnal cycle.
When evaluating the temperature of older adults, the nurse
should rememberwhich aspect about an older adult’s body
temperature?
a. The body temperature of the older adult is lower than
that of a youngeradult.
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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 overthe last 6 weeks. The
nurse knows that:
a. Unexplained weight loss often accompanies short-term
illnesses.
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.
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 becompared with the thigh pressure.
The nurse is preparing to measure the vital signs of a 6-month-
old infant. Whichaction by the nurse is correct?
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a. Respirations are measured; then pulse and temperature.
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’svital signs?
a. The nurse should auscultate an apical rate for 1 minute and
then assess for any normal irregularities, such as sinus
arrhythmia.
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 areexpected findings.
In a patient with acromegaly, the nurse will expect to discover
which assessmentfindings?
a. Overgrowth of bone in the face, head, hands, and feet
The nurse is performing a general survey of a patient. Which
finding is considerednormal?
a. Arm span (fingertip to fingertip) equals the patient’s height.
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 thediastolic reading in children.
What type of blood pressure measurement error is most
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likely to occur if the nurse does not check for the presence of
an auscultatory gap?
a. Systolic blood pressure may be falsely low.
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 thecardiac cycle.
A 75-year-old man with a history of hypertension was recently
changed to a newantihypertensive 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, andstanding positions.
Which of these specific measurements is the best index of a
child’s generalhealth?
a. Height and weight
The nurse is assessing an 8-year-old child whose growth rate
measures below thethird percentile for a child his age. He
appears significantly younger than his stated age and is chubby
with infantile facial features. Which condition does thischild
have?
a. Hypopituitary dwarfism
The nurse is counting an infant’s respirations. Which technique is
correct?
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a. Watching the abdomen for movement
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 thebasis of this observation, the
nurse should:
a. Recognize that a tripod position is often used when a
patient is havingrespiratory difficulties.
Which of these actions illustrates the correct technique the
nurse should usewhen assessing oral temperature with a
mercury thermometer?
a. Leave the thermometer in place 3 to 4 minutes if the patient
is afebrile.
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 rectalroute.
To assess a rectal temperature accurately in an adult, the nurse
would:
a. Use a lubricated blunt tip thermometer.
Which technique is correct when the nurse is assessing the
radial pulse of apatient?
The pulse is counted for:
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a. 1 minute, if the rhythm is irregular.
When assessing a patient’s pulse, the nurse should also notice
which of thesecharacteristics?
a. Force
When assessing the pulse of a 6-year-old boy, the nurse notices
that his heart ratevaries 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.
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.
The nurse is assessing the vital signs of a 20-year-old male
marathon runner anddocuments 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.
The nurse is assessing the vital signs of a 3-year-old patient who
appears to havean 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.
A patient’s blood pressure is 118/82 mm Hg. He asks the nurse,
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“What do thenumbers mean?” The nurse’s best reply is:
a. “The top number is the systolic blood pressure and reflects
the pressure ofthe blood against the arteries when the heart
contracts.”
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While measuring a patient’s blood pressure, the nurse recalls
that certain factors,such as , help determine blood pressure.
a. Peripheral vascular resistance
A nurse is helping at a health fair at a local mall. When taking
blood pressures ona variety of people, the nurse keeps in mind
that:
a. The blood pressure of a Black adult is usually higher than
that of a Whiteadult of the same age.
The nurse notices a colleague is preparing to check the blood
pressure of a patientwho is obese by using a standard-sized blood
pressure cuff. The nurse should expect the reading to:
a. Yield a falsely high blood pressure.
A student is late for his appointment and has rushed across
campus to the healthclinic. The nurse should:
a. Allow 5 minutes for him to relax and rest before checking his
vital signs.
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.
The nurse is taking an initial blood pressure reading on a 72-
year-old patient withdocumented hypertension. How should the
nurse proceed?
a. Cuff should be inflated 30 mm Hg above the point at
which the palpatedpulse disappears.
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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
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 Korotkoffsounds muffle. At 92 mm Hg,
the Korotkoff sounds disappear. How should the nurse record
this patient’s blood pressure?
a. 200/92
A patient is seen in the clinic for complaints of “fainting episodes
that started lastweek.” How should the nurse proceed with the
examination?
a. His blood pressure is recorded in the lying, sitting, and
standing positions.
When checking for proper blood pressure cuff size, which
guideline is correct?
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a. The width of the rubber bladder should equal
40% of the armcircumference.
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 withbruises. The nurse determines
that the patient has which condition?
a. Cushing syndrome
27. MULTIPLE RESPONSE
1. While measuring a patient’s blood pressure, the nurse uses the
proper technique toobtain 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.
.
29. SHORT ANSWER
2. What is the pulse pressure for a patient whose blood pressure is
158/96 mm Hgand whose pulse rate is 72 beats per minute?
158-96=62
30.
31.
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When assessing the quality of a patient’s pain, the nurse
should ask whichquestion?
a.
“What does your pain feel like?”
When assessing a patient’s pain, the nurse knows that an example
of visceral painwould be:
a. Cholecystitis.
The nurse is reviewing the principles of nociception. During
which phase ofnociception does the conscious awareness of a
painful sensation occur?
a. Perception
When assessing the intensity of a patient’s pain, which question
by the nurse isappropriate?
a.
“How much pain do you have now?”
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
The nurse knows that which statement is true regarding the
pain experienced byinfants?
a. A procedure that induces pain in adults will also induce pain
in the infant.
A patient has been admitted to the hospital with vertebral
fractures related to osteoporosis. She is in extreme pain. This
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type of pain would be classified as:
a. Deep somatic.
32. Chapter 10: Pain Assessment: The Fifth Vital Sign
When evaluating a patient’s pain, the nurse knows that an
example of acute painwould be:
a. Kidney stones.
Which statement indicates that the nurse understands the pain
experienced by anolder adult?
a.
“Pain indicates a pathologic condition or an injury and
is not a normalprocess of aging.”
A 4-year-old boy is brought to the emergency department by his
mother. She sayshe 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)
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 findingsindicates an acute pain response to
poorly controlled pain?
a. Increased blood pressure and pulse
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:
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a. Slightest touch, such as a sleeve brushing against her arm,
causes severeand intense pain.
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The nurse is assessing a patient’s pain. The nurse knows that
the most reliableindicator of pain would be the:
a. Subjective report.
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.
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 nervoussystem?
.
34. MULTIPLE RESPONSE
1.
During assessment of a patient’s pain, the nurse is aware that
certain nonverbalbehaviors 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 forpain because the patient has recently had
several falls. Which of these are appropriate for the nurse to
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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.
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. Chapter 11: Nutritional Assessment
The nurse is performing a nutritional assessment on a 15year-old girl whotells 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?”
The nurse is discussing appropriate foods with the mother
of a 3-year-oldchild. Which of these foods are
recommended?
a. Finger foods and nutritious snacks that cannot cause choking
The nurse is reviewing the nutritional assessment of an 82year-old patient. Which of these factors will most likely affect
the nutritional status of an olderadult?
a. Living alone on a fixed income
When considering a nutritional assessment, the nurse is
aware that the mostcommon anthropometric measurements
include:
a. Height and weight.
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 thewoman’s weight?
a. Obese
How should the nurse perform a triceps skinfold assessment?
a. After applying the calipers, the nurse waits 3 seconds
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before taking a reading. After repeating the procedure
three times, an average is recorded.
In teaching a patient how to determine total body fat at
home, the nurseincludes instructions to obtain
measurements of:
a. Height and weight.
The nurse is evaluating patients for obesity-related diseases by
calculating thewaist-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 36inches
A 50-year-old woman with elevated total cholesterol and
triglyceride levels isvisiting 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.
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
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?
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a. Decreased serum albumin
The nurse is performing a nutritional assessment on an 80year-old patient. The nurse knows that physiologic changes
can directly affect the nutritionalstatus of the older adult
and include:
a. Slowed gastrointestinal motility.
Which of these interventions is most appropriate when the
nurse is planningnutritional interventions for a healthy,
active 74-year-old woman?
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a. Decreasing the number of calories she is eating because of
the decrease in energy requirements from the loss of lean
body mass
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 weekdaysand 1 weekend day
The nurse is preparing to measure fat and lean body mass
and bone mineraldensity. Which tool is appropriate?
a. Dual-energy x-ray absorptiometry (DEXA)
Which of these conditions is due to an inadequate intake of
both protein andcalories?
a. Marasmus
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 ofa deficiency in what mineral
and/or vitamin?
a. Riboflavin
A 50-year-old patient has been brought to the emergency
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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 adeficiency of:
a. Vitamin D and calcium.
An older adult patient in a nursing home has been receiving
tube feedings forseveral 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
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:
Experiencing moderate malnutrition.
The nurse recognizes which of these persons is at
greatest risk forundernutrition?
a. 5-month-old infant
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When assessing a patient’s nutritional status, the nurse
recalls that the bestdefinition of optimal nutritional status
is sufficient nutrients that:
a. Provide for daily body requirements and support
increased metabolicdemands.
The nurse is providing nutrition information to the mother of
a 1-year-old child. Which of these statements represents
accurate information for this agegroup?
a. Maintaining adequate fat and caloric intake is important
for a child in thisage group.
A pregnant woman is interested in breastfeeding her baby
and asks several questions about the topic. Which
information is appropriate for the nurse toshare with her?
a. Breast milk provides the nutrients necessary for growth, as
well as naturalimmunity.
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.
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
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expect to find?
a. Osteomalacia (softening of the bones)
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
A patient is asked to indicate on a form how many times he
eats a specificfood. This method describes which of these
tools for obtaining dietary information?
a. Food-frequency questionnaire
The nurse is providing care for a 68-year-old woman who is
complaining ofconstipation. What concern exists regarding
her nutritional status?
a. Absorption of nutrients may be impaired.
During a nutritional assessment, why is it important for
the nurse to ask apatient what medications he or she is
taking?
a. Certain drugs can affect the metabolism of nutrients.
A patient tells the nurse that his food simply does not have any
taste anymore.The nurse’s best response would be:
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a.
“When did you first notice this change?”
.
MULTIPLE RESPONSE
The nurse is assessing a patient who is obese for signs of
1.
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.
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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 usualweight is 175 pounds, but today
she weighs 161 pounds. What is her recent weight change
percentage? To calculate recent weight change percentage, use
thisformula:
45.
Usual weight – current weight
46.
100
usual weight
47.
48. 175 – 161 = 14 pounds
49. 14 ÷ 175 = 0.08
50. 0.08
100 = 8%
51.
52.
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