Health Assessment Exam 1: Study Guide

1 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Health Assessment Exam1: Study Guide Chapter 1 1. After completing an initial assessment of a patient, the nurse has charted that his respirationsare eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. 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 introspective are not used to describe data. 2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These typesof data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. 2 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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 and introspective are not used to describe data. 3. The patient’s record, laboratory studies, objective data, and subjective data combine toform the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary. Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patient’s record, laboratorystudies, or data. 3 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard.The nurse’s next action should be to: a. Immediately notify the patient’s physician. b. Document the sound exactly as it washeard. c. Validate the data by asking a coworker tolisten to the breath sounds. d. Assess again in 20 minutes to notewhether the sound is still present. When unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then heor she asks an expert to listen. 5. The nurse is conducting a class for new graduate nurses. During the teaching session, thenurse 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. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors. 4 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Novice nurses operate from a set of defined, structured rules. The expert practitioner usesintuitive links. 6. Expert nurses learn to attend to a pattern of assessment data and act without consciouslylabeling it. These responses are referred to as: a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning. 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 arenot correct. 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? 5 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. EBP relies on tradition for support of bestpractices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidencewith the clinician’s experience. d. The patient’s own preferences are notimportant with EBP. EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the bestpractice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. 8. The nurse is conducting a class on priority setting for a group of new graduate nurses.Which is an example of a first-level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabeteswho needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath andrespiratory distress 6 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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). 9. When considering priority setting of problems, the nurse keeps in mind that second- levelpriority problems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs 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). 7 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 10. 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 Clustering related cues helps the nurse see relationships among the data. 11. The nurse knows that developing appropriate nursing interventions for a patient relies onthe appropriateness of the diagnosis. a. Nursing b. Medical c. Admission d. Collaborative 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 contributeto the development of appropriate nursing interventions. 8 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 12. The nursing process is a sequential method of problem solving that nurses use andincludes which steps? a. Assessment, treatment, planning, evaluation, discharge, and followup b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation,and evaluation The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is havingdifficulty breathing. How should the nurse prioritize these problems? 9 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. 14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. 15. Barriers to incorporating EBP include: a. Nurses’ lack of research skills in evaluating the quality of research studies. 10 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills. 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 thetime to visit the library to read research. The other responses are not considered barriers. 16. What step of the nursing process includes data collection by health history, physicalexamination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment 11 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2). 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestionby the nurse manager would best help these problems? a. Form a committee to conduct researchstudies. b. Post published research studies on theunit’s bulletin boards. c. Encourage the nurses to visit the library toreview studies. d. Teach the nurses how to conduct electronic searches for research studies. Facilitating support for EBP would include teaching the nurses how to conduct electronicsearches; 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 solutionto reviewing existing research. 18. When reviewing the concepts of health, the nurse recalls that the components of holistichealth include which of these? a. Disease originates from the externalenvironment. b. The individual human is a closed system. 12 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. Nurses are responsible for a patient’shealth state. d. Holistic health views the mind, body, and spirit as interdependent. 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 the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. 19. The nurse recognizes that the concept of prevention in describing health is essentialbecause: a. Disease can be prevented by treating theexternal environment. b. The majority of deaths among Americans 13 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 under age 65 years are not preventable. c. Prevention places the emphasis on the linkbetween health and personal behavior. d. The means to prevention is through treatment provided by primary health carepractitioners. 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. 20. The nurse is performing a physical assessment on a newly admitted patient. An exampleof objective information obtained during the physical assessment includes the: a. Patient’s history of allergies. b. Patient’s use of medications at home. c. Last menstrual period 1 month ago. d. 2 × 5 cm scar on the right lower forearm. Objective data are the patient’s record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during thephysical examination. The other responses reflect subjective data. 14 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changesat appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because ofthe nurse’s primary responsibility for monitoring the patient’s health d. An emergency data base because of theneed to collect information and make accurate diagnoses rapidly The complete data base is collected in a primary care setting, such as a pediatric or familypractice clinic, independent or group private practice, college health service, women’s health care agency, visiting nurse agency, or community health agency. In these settings, 15 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 the nurse is the first health professional to see the patient and has the primaryresponsibility for monitoring the person’s health care. 22. Which situation is most appropriate during which the nurse performs a focused orproblem-centered history? a. Patient is admitted to a long-term carefacility. b. Patient has a sudden and severe shortnessof breath. c. Patient is admitted to the hospital forsurgery the following day. d. Patient in an outpatient clinic has cold andinfluenza-like symptoms. 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 concernsone problem, one cue complex, or one body system. 23. A patient is at the clinic to have her blood pressure checked. She has been coming to theclinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and thencheck her blood pressure. b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure becauseher complete health history 16 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because muchof her history information may have changed. A follow-up data base is used in all settings to follow up short-term or chronic healthproblems. The other responses are not appropriate for the situation. 24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quitesevere. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination andinstitute life-saving measures. b. Simultaneously ask history questions 17 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 while performing the examination andinitiating life-saving measures. c. Collect all information on the history form, including social support patterns,strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive careunit. 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. 25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his healthassessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for theindividual. d. Provide culturally sensitive and appropriate care. The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening withculturally sensitive and appropriate care. 18 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 26. In the health promotion model, the focus of the health professional includes: a. Changing the patient’s perceptions ofdisease. b. Identifying biomedical model interventions. c. Identifying negative health acts of theconsumer. d. Helping the consumer choose a healthierlifestyle. In the health promotion model, the focus of the health professional is on helping theconsumer choose a healthier lifestyle. 19 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 27. The nurse has implemented several planned interventions to address the nursingdiagnosis of acute pain. Which would be the next appropriate action? a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individual’s condition, and compare actual outcomes with expectedoutcomes. d. Interpret data, and then identify clusters ofcues and make inferences. Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individual’s condition and compares the actual outcomeswith expected outcomes (See Figure 1-2). 28. 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 theaccurate solution. c. Sees actions in the context of daily plansfor patients. d. Understands a patient situation as a wholerather than a list of tasks and recognizes the long-term goals for the patient. 20 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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 nurseis able to see how today’s nursing actions can apply to the point the nurse wants the patient to reach at a future time. MULTIPLE RESPONSE 1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Inspiratory wheezes noted in left lowerlobes 21 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute Clustering related cues help the nurse recognize relationships among the data. The cues related to the patient’s respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and peripheral edemaare not related to the respiratory cues. MATCHING 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 duringa soccer match is having trouble breathing. c. An older adult with a urinary tractinfection is also showing signs of confusion and agitation. 22 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 1. a = First-level priority problem 2. b = Second-level priority problem 3. c = Third-level priority problem Chapter 2 1. The nurse is reviewing the development of culture. Which statement is correct regarding thedevelopment of one’s culture? Culture is: a. Genetically determined on the basis ofracial background. b. Learned through language acquisition andsocialization. 23 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. A nonspecific phenomenon and isadaptive but unnecessary. d. Biologically determined on the basis of physical characteristics. Culture is learned from birth through language acquisition and socialization. It is notbiologically or genetically determined and is learned by the individual. 2. During a class on the aspects of culture, the nurse shares that culture has four basiccharacteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging,despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a person’s language and behavior. d. Culture adapts to specific environmentalfactors and available natural resources. Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technical factors and to the availability of natural resources, and it is dynamic and ever changing. Culture is learned from birth through the process of language acquisition and socialization, but it is not most clearly reflected in one’s language and behavior. 24 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definitionstating “the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society” reflects which term? a. Mores b. Norms c. Culture d. Social learning The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members ofthe society. The other terms do not fit the given definition. 4. When discussing the use of the term subculture, the nurse recognizes that it is bestdescribed as: a. Fitting as many people into the majorityculture as possible. b. Defining small groups of people who do 25 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 not want to be identified with the largerculture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture. Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender.When such groups function within a large culture, they are referred to as subcultural groups. 5. When reviewing the demographics of ethnic groups in the United States, the nurse recallsthat the largest and fastest growing population is: a. Hispanic. b. Black. c. Asian. d. American Indian. Hispanics are the largest and fastest growing population in the United States, followed by Asians, Blacks, American Indians and Alaska natives, and other groups. 6. During an assessment, the nurse notices that a patient is handling a small charm that istied to a leather strip around his neck. Which action by the nurse is appropriate? 26 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Ask the patient about the item and itssignificance. b. Ask the patient to lock the item with othervaluables in the hospital’s safe. c. Tell the patient that a family membershould take valuables home. d. No action is necessary. The nurse should inquire about the amulet’s meaning. Amulets, such as charms, are often considered an important means of protection from “evil spirits” by some cultures. 7. The nurse manager is explaining culturally competent care during a staff meeting. Whichstatement accurately describes the concept of culturally competent care? “The caregiver: a. Is able to speak the patient’s nativelanguage.” 27 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Possesses some basic knowledge of thepatient’s cultural background.” c. Applies the proper background knowledgeof a patient’s cultural background to provide the best possible health care.” d. Understands and attends to the totalcontext of the patient’s situation.” Culturally competent implies that the caregiver understands and attends to the total context of the individual’s situation. This competency includes awareness of immigrationstatus, stress factors, other social factors, and cultural similarities and differences. It doesnot require the caregiver to speak the patient’s native language. 8. The nurse recognizes that an example of a person who is heritage consistent would be a: a. Woman who has adapted her clothing tothe clothing style of her new country. b. Woman who follows the traditions that hermother followed regarding meals. c. Man who is not sure of his ancestor’scountry of origin. d. Child who is not able to speak his parents’ native language. Someone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage, not the norms and customs of the new country. 28 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 9. After a class on culture and ethnicity, the new graduate nurse reflects a correctunderstanding of the concept of ethnicity with which statement? a. “Ethnicity is dynamic and ever changing.” b. “Ethnicity is the belief in a higher power.” c. “Ethnicity pertains to a social group within the social system that claims sharedvalues and traditions.” d. “Ethnicity is learned from birth through the processes of language acquisition andsocialization.” Ethnicity pertains to a social group within the social system that claims to have variabletraits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences. Culture is dynamic, ever changing, andlearned from birth through the processes of language acquisition and socialization. 29 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Religion is the belief in a higher power. 10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one’s spirituality? a. Belief in and the worship of God or gods b. Attendance at a specific church or place ofworship c. Personal effort made to find purpose andmeaning in life d. Being closely tied to one’s ethnic background Spirituality refers to each person’s unique life experiences and his or her personal effortto find purpose and meaning in life. The other responses apply to religion. 11. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresseslike her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. This concept does not reflect heritage 30 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 consistency. Biculturalism is a dual pattern of identification; acculturation is the processof adapting to and acquiring another culture. 12. The nurse is conducting a heritage assessment. Which question is most appropriate forthis assessment? a. “What is your religion?” b. “Do you mostly participate in the religious traditions of your family?” c. “Do you smoke?” d. “Do you have a history of heart disease?” Asking questions about participation in the religious traditions of family enables the nurse to assess a person’s heritage. Simply asking about one’s religion, smoking history,or health history does not reflect heritage. 31 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 13. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably becauseMexican-Americans: a. Have less efficient immune systems andare often ill. b. Consider these symptoms part of normalliving, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick. The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group definehealth. 14. The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is abasic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious 32 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic, or holistic, perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forcesdominate and cause illness or health. 15. An Asian-American woman is experiencing diarrhea, which is believed to be “cold” or “yin.” The nurse expects that the woman is likely to try to treat it with: a. Foods that are “hot” or “yang.” b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be“cold.” d. No treatment is tried because diarrhea isan expected part of life. 33 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. The other explanations do not reflect the yin/yang theory. 16. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects “health” in an Asian withthis belief? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfectbalance. d. A person is able to care for others andfunction socially. Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory. 17. Illness is considered part of life’s rhythmic course and is an outward sign of disharmonywithin. This statement most accurately reflects the views about illness from which theory? a. Naturalistic b. Biomedical c. Reductionist d. Magicoreligious 34 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From the perspective of the Chinese, for example, illness is not considered an introducing agent; rather, illness is considered a part of life’s rhythmic course and an outward sign of disharmony within. The other options are not correct. 18. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or her spiritual nature. The basic premise of the magicoreligious perspective is that the world is seen as an arena 35 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective. 19. If an American Indian woman has come to the clinic to seek help with regulating herdiabetes, then the nurse can expect that she: a. Will comply with the treatmentprescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of ashaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith. When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seekhelp from folk or religious healers. 20. An older Mexican-American woman with traditional beliefs has been admitted to aninpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator aboutthe best course of action. 36 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Automatically get a curandero for her,because requesting one herself is not culturally appropriate. c. Further assess the patient’s cultural beliefsand offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families. In addition to seeking help from the biomedical or scientific health care provider, patientsmay also seek help from folk or religious healers. Some people, such as those of Mexican-American or American-Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into 37 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 parts is a Western concept). 21. A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse’sbest course of action? a. The nurse should focus on performing afull cardiac assessment. b. The nurse should focus on psychosomaticcomplaints because the patient has just learned that his wife has cancer. c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact hisphysician. d. It is unclear what is happening with thispatient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms. Wide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart). 22. Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which ofthe following is a true statement regarding pain? 38 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Nurses’ attitudes toward their patients’pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as aresponse to pain. c. A nurse’s area of clinical practice will most likely determine his or her assessment of a patient’s pain. d. A nurse’s years of clinical experience and current position are strong indicators of his or her response to patient pain. Silent suffering is a potential response to pain in many cultures. The nurse’s assessmentof pain needs to be embedded in a cultural context. The other responses are not correct. 39 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 23. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressionsof pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d. A patient’s expression of pain is largely dependent on the amount of tissue injuryassociated with the pain. In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to theirsocial environment for validation and comparison. The other statements are incorrect. 24. During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? “Spirituality: a. Is a personal search to discover a supremebeing.” b. Is an organized system of beliefs concerning the cause, nature, and purposeof the universe.” 40 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. Is a belief that each person exists foreverin some form, such as a belief in reincarnation or the afterlife.” d. Arises out of each person’s unique life experience and his or her personal effortto find purpose in life.” Spirituality arises out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. The other definitions reflect the concept of religion. 25. The nurse recognizes that working with children with a different cultural perspective maybe especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are 41 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents’ perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their children’sspiritual needs. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child’s developmental level and the religious climate that exists in the family. The other statements are not correct. 26. A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman’s sister until they can get a home of their own. When companyarrives to visit with the woman’s sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests issimply because she does not know how to speak “perfect English.” This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individual’s perceptions and expectations. The other terms are not correct. 42 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 27. After a symptom is recognized, the first effort at treatment is often self-care. Which of thefollowing statements about self-care is true? “Self-care is: a. Not recognized as valuable by most healthcare providers.” b. Usually ineffective and may delay more effective treatment.” c. Always less expensive than biomedical alternatives.” d. Influenced by the accessibility of overthe-counter medicines.” After a symptom is identified, the first effort at treatment is often self-care. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the mass media in communicating health-related 43 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 information to the general population have contributed to the high percentage of cases ofself-treatment. 28. The nurse is reviewing the hot/cold theory of health and illness. Which statement bestdescribes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence thehumors of the body. b. Herbs and medicines are classified on their physical characteristics of hot andcold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of theindividual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness,or wetness to restore the balance of the humors of the body. The hot/cold theory of health and illness is based on the four humors of the body: blood,phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance ofthe humors. The other statements are not correct. 29. In the hot/cold theory, illnesses are believed to be caused by hot or cold entering thebody. Which of these patient conditions is most consistent with a cold condition? a. Patient with diabetes and renal failure 44 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Teenager with an abscessed tooth c. Child with symptoms of itching and a rash d. Older man with gastrointestinaldiscomfort Illnesses believed to be caused by cold entering the body include earache, chest cramps, gastrointestinal discomfort, rheumatism, and tuberculosis. Those illnesses believed to be caused by heat, or overheating, include sore throats, abscessed teeth, rashes, and kidney disorders. 30. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiatingan assessment of cultural beliefs with an older American-Indian patient? 45 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. “Are you of the Christian faith?” b. “Do you want to see a medicine man?” c. “How often do you seek help frommedical providers?” d. “What cultural or spiritual beliefs areimportant to you?” The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best usedinitially when performing a cultural assessment. 31. During a class on cultural practices, the nurse hears the term cultural taboo. Whichstatement illustrates the concept of a cultural taboo? a. Believing that illness is a punishment of sin b. Trying prayer before seeking medical help c. Refusing to accept blood products as partof treatment d. Stating that a child’s birth defect is theresult of the parents’ sins Cultural taboos are practices that are to be avoided, such as receiving blood products, eating pork, and consuming caffeine. The other answers do not reflect cultural taboos. 32. The nurse recognizes that categories such as ethnicity, gender, and religion illustrate theconcept of: 46 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Family. b. Cultures. c. Spirituality. d. Subcultures. Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender.When such groups function within a large culture, they are referred to as subcultural groups. 33. The nurse is reviewing concepts related to one’s heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of theuniverse is known as: a. Culture. 47 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Religion. c. Ethnicity. d. Spirituality. Religion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Spirituality is born out of each person’s unique life experiences and his or her personal efforts to find purpose and meaning in life. Ethnicity pertains to a social group within the social systemthat claims to possess variable traits, such as a common geographic origin, religion, race,and others. 34. When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health-related beliefs Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient’s history. 35. Which of the following reflects the traditional health and illness beliefs and practices ofthose of African heritage? Health is: a. Being rewarded for good behavior. b. The balance of the body and spirit. 48 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. Maintained by wearing jade amulets. d. Being in harmony with nature. The belief that health is being in harmony with nature reflects the health beliefs of thoseof African heritages. The other examples represent Iberian and Central and South American heritages, American-Indian heritages, and Asian heritages (See Table 2-3). MULTIPLE RESPONSE 1. The nurse is reviewing aspects of cultural care. Which statements illustrate propercultural care? Select all that apply. a. Examine the patient within the context ofone’s own cultural health and illness practices. b. Select questions that are not complex. c. Ask questions rapidly. 49 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 d. Touch patients within the culturalboundaries of their heritage. e. Pace questions throughout the physicalexamination. Patients should be examined within the context of their own cultural health and illness practices. Questions should be simply stated and not rapidly asked. 2. The nurse is asking questions about a patient’s health beliefs. Which questions areappropriate? Select all that apply. a. “What is your definition of health?” b. “Does your family have a history of cancer?” c. “How do you describe illness?” d. “What did your mother do to keep youfrom getting sick?” e. “Have you ever had any surgeries?” f. “How do you keep yourself healthy?” The questions listed are appropriate questions for an assessment of a patient’s health beliefs and practices. The questions regarding family history and surgeries are part of thepatient’s physical history, not the patient’s health beliefs. Chapter 4 50 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 1. The nurse is preparing to conduct a health history. Which of these statements best describesthe purpose of a health history? a. To provide an opportunity for interactionbetween the patient and the nurse b. To provide a form for obtaining thepatient’s biographic information c. To document the normal and abnormalfindings of a physical assessment d. To provide a database of subjective information about the patient’s past andcurrent 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. 2. When the nurse is evaluating the reliability of a patient’s responses, which of thesestatements would be correct? The patient: 51 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Has a history of drug abuse and thereforeis not reliable. b. Provided consistent information andtherefore is reliable. c. Smiled throughout interview and thereforeis assumed reliable. d. Would not answer questions concerningstress and therefore is not reliable. A reliable person always gives the same answers, even when questions are rephrased orare repeated later in the interview. The other statements are not correct. 3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason forseeking care? a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states thathe has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having “black stools” for thepast 24 hours. 52 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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 two) signs or symptoms andtheir duration. It is enclosed in quotation marks to indicate the person’s exact words. 4. A patient tells the nurse that she has had abdominal pain for the past week. What wouldbe the nurse’s best response? a. “Can you point to where it hurts?” b. “We’ll talk more about that later in theinterview.” c. “What have you had to eat in the last 24hours?” d. “Have you ever had any surgeries on yourabdomen?” A final summary of any symptom the person has should include, along with seven other 53 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 critical characteristics, “Location: specific.” The person is asked to point to the location. 5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Whichwould 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 nerve.” c. “I’ve had back pain myself, and it can be excruciating.” 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 affectshis or her daily activities. The other responses are not appropriate. 6. In recording the childhood illnesses of a patient who denies having had any, which noteby 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 measles, but hedidn’t. d. Patient denies measles, mumps, rubella,chickenpox, pertussis, and strep throat. 54 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles). 7. A female patient tells the nurse that she has had six pregnancies, with four live births atterm 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, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times. Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of 55 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav Term Preterm Ab Living . For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in aspontaneous (S) or an induced (I) abortion. 8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s bestresponse 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 won’t receive any penicillin.” d. “Describe what happens to you when youtake penicillin.” 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 allergic reaction. 9. The nurse is taking a family history. Important diseases or problems about which thepatient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness. d. Fractured bones. 56 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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, suicide, seizure disorder, kidney disease, and tuberculosis should be asked. 10. The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotionpractices. c. An opportunity to teach the patientmedical terms. d. Information necessary for the nurse to diagnose the patient’s medical problem. The purposes of the review of systems are to: (1) evaluate the past and current health 57 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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 practices. 11. Which of these statements represents subjective data the nurse obtained from the patientregarding 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 theright arm. The history should be limited to patient statements or subjective data—factors that the person says were or were not present. 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned abouthealth promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. “Do you perform testicular selfexaminations?” b. “Have you ever noticed any pain in your testicles?” c. “Have you had any problems with passing urine?” d. “Do you have any history of sexually 58 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 transmitted diseases?” Health promotion for a man would include the performance of testicular selfexaminations. The other questions are asking about possible disease or illness issues. 13. Which of these responses might the nurse expect during a functional assessment of apatient 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 color of my toes every evening just like I was taught.” d. “I’m able to transfer myself from thewheelchair to the bed without help.” 59 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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. 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 mostappropriate? a. “This has been a difficult year for you.” b. “I don’t know how anyone could handlethat much stress in 1 year!” c. “What did you do to cope with the loss ofboth your husband and mother?” d. “That is a lot of stress; now let’s go on to the next section of your history.” Questions about coping and stress management include questions regarding the kinds ofstresses 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 been helpful. 15. In response to a question regarding the use of alcohol, a patient asks the nurse why thenurse needs to know. What is the reason for needing this information? a. This information is necessary to determinethe patient’s reliability. b. Alcohol can interact with all medications and can make some diseases worse. 60 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless adrinking problem is obvious. 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 contributesto many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct. 16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache.What would be an appropriate response? a. “Maybe she is just teething.” b. “I will check her ear for an ear infection.” c. “Are you sure she is really having pain?” 61 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 d. “Describe what she is doing to indicateshe is having pain.” 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 pain do not explore the symptoms, which should be done before a physical examination. 17. 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 nearrelatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age ofimmediate family members c. Drawing that depicts the patient’s familymembers up to five generations back d. Description of the health of a person’schildren and grandchildren 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. 18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Whichinformation should the nurse collect before this procedure? 62 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Child’s birth weight b. Age at which he crawled c. Whether the child has had the measles d. Child’s reactions to previous hospitalizations 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 significant for the procedure. 19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? 63 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at4 to 6 years of age. c. MMR immunization needs to be repeatedevery 4 years until age 21 years. d. A recommendation cannot be made untilthe physician is consulted. 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 monthsof age and one at age 4 to 6 years. 20. In obtaining a review of systems on a “healthy” 7-year-old girl, the health care providerknows 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. Limitations related to her involvement insports activities. When reviewing the cardiovascular system, the health care provider should ask whetherany activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age. 64 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 21. When the nurse asks for a description of who lives with a child, the method of discipline,and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care 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 rationalefor requesting health care. 22. The nurse is obtaining a health history on an 87-year-old woman. Which of the followingareas of questioning would be most useful at this time? 65 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Obstetric history b. Childhood illnesses c. General health for the past 20 years d. Current health promotion activities 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. 23. The nurse is performing a review of systems on a 76-year-old patient. Which of thesestatements is correct for this situation? a. The questions asked are identical for allages. b. The interviewer will start incorporating different questions for patients 70 years ofage and older. c. Questions that are reflective of the normaleffects of aging are added. d. At this age, a review of systems is not necessary—the focus should be on currentproblems. 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 theactivities of daily living may have been affected by the normal aging processes or by theeffects of chronic illness or disability. 66 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 24. A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate responsefrom the nurse would be: a. “Can you tell me what they look like?” b. “Don’t worry about it. You are only taking two medications.” c. “How long have you been taking each of the pills?” d. “Would you have a family member bring in your medications?” 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 helpto identify the medications. 67 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 25. The nurse is performing a functional assessment on an 82-year-old patient who recentlyhad 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?” d. “How many times a day do you have a bowel movement?” 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. 26. The nurse is preparing to do a functional assessment. Which statement best describes thepurpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meetingdevelopmental milestones. c. The functional assessment can identify any problems with memory the individualmay be experiencing. d. It helps determine how a person ismanaging day-to-day activities. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment. 68 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 27. The nurse is asking a patient for his reason for seeking care and asks about the signs andsymptoms 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 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. 28. A patient is describing his symptoms to the nurse. Which of these statements reflects adescription of the setting of his symptoms? 69 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. “It is a sharp, burning pain in my stomach.” b. “I also have the sweats and nausea when Ifeel this pain.” c. “I think this pain is telling me that something bad is wrong with me.” d. “This pain happens every time I sit down to use the computer.” The setting describes where the person is or what the person is doing when the symptomstarts. 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 wrong with him reflects the patient’s perception of the pain; and describing the “sweats and nausea” reflects associated factors that occur with the pain. 29. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two ofthe 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 possible alcohol withdrawalsymptoms. d. The nurse should suspect alcohol abuseand continue with a more thorough substance abuse assessment. 70 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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. 30. The nurse is incorporating a person’s spiritual values into the health history. Which ofthese questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. “Do you believe in God?” b. “Are you a part of any religious or spiritual congregation?” c. “Do you consider yourself to be a religious or spiritual person?” d. “How does your religious faith influence the way you think about your health?” 71 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 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, andaddressing any religious or spiritual issues or concerns. 31. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for theparents before the interview begins? a. “Please stay during the interview; you cananswer for her if she does not know the answer.” b. “It would help to interview the three ofyou together.” c. “While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?” d. “While I interview your daughter, will you step out to the waiting room and completethese family health history questionnaires?” The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires. 32. The nurse is assessing a new patient who has recently immigrated to the United States.Which question is appropriate to add to the health history? a. “Why did you come to the United States?” b. “When did you come to the United 72 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Statesand from what country?” c. “What made you leave your nativecountry?” d. “Are you planning to return to yourhome?” 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 reflectappropriate questions. MULTIPLE RESPONSE 1. The nurse is assessing a patient’s headache pain. Which questions reflect one or more ofthe critical characteristics of symptoms that should be assessed? Select all that apply. a. “Where is the headache pain?” 73 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. “Did you have these headaches as achild?” c. “On a scale of 1 to 10, how bad is the pain?” d. “How often do the headaches occur?” e. “What makes the headaches feel better?” f. “Do you have any family history of headaches?” 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; and (6) U: understand the patient’s perception. Asking, “Where is the pain?” reflects “region.” Asking the patient to rate the pain on a 1 to 10 scale reflects “severity.” Asking “How often…” reflects “timing.” Asking what makes the pain better reflects “provocative.” The other options reflect health history and family history. 2. The nurse is conducting a developmental history on a 5-year-old child. Which questionsare 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, and whendid he lose them?” c. “Is he able to tie his shoelaces?” d. “Does he take a children’s vitamin?” e. “Can he tell time?” 74 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 f. “Does he have any food allergies?” 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 vitaminsare part of a nutritional history. Questions about food allergies are not part of a developmental history. Chapter 5 1. During an examination, the nurse can assess mental status by which activity? a. Examining the patient’s electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test 75 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. Observing the patient and inferring healthor dysfunction d. Examining the patient’s response to aspecific set of questions Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects. 2. The nurse is assessing the mental status of a child. Which statement about children andmental status is true? a. All aspects of mental status in children areinterdependent. b. Children are highly labile and unstable until the age of 2 years. c. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years. d. A child’s mental status is impossible to assess until the child develops the abilityto concentrate. Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true. 76 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 3. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion ofthe assessment, the nurse expects that this patient: a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should nothave declined. d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge. The aging process leaves the parameters of mental status mostly intact. General 77 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected. 4. When assessing aging adults, the nurse knows that one of the first things that should beassessed before making judgments about their mental status is: a. Presence of phobias b. General intelligence c. Presence of irrational thinking patterns d. Sensory-perceptive abilities Age-related changes in sensory perception can affect mental status. For example, visionloss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, andsocial isolation and makes the person appear confused. 5. The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient’s family is the best resource forinformation about the patient’s coping skills. b. Gathering mental status information during the health history interview is usually sufficient. 78 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient’s level offunctioning, performing a complete mental status examination is usually necessary. The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. 6. A woman brings her husband to the clinic for an examination. She is particularly worriedbecause after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action? a. Perform a complete mental statusexamination. 79 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physicalexamination. d. Reassure his wife that memory loss after aphysical shock is normal and will soon subside. Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury. 7. The nurse is conducting a patient interview. Which statement made by the patient shouldthe nurse more fully explore during the interview? a. “I sleep like a baby.” b. “I have no health problems.” c. “I never did too good in school.” d. “I am not currently taking any medications.” In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which maycause confusion or depression; the usual educational and behavioral level, noting this level as the patient’s normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits. 80 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 8. A patient is admitted to the unit after an automobile accident. The nurse begins the mentalstatus examination and finds that the patient has dysarthric speech and is lethargic. The nurse’s best approach regarding this examination is to: a. Plan to defer the rest of the mental statusexamination. b. Skip the language portion of the examination, and proceed onto assessingmood and affect. c. Conduct an in-depth speech evaluation, and defer the mental status examination toanother time. d. Proceed with the examination, and assessthe patient for suicidal thoughts because 81 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 dysarthria is often accompanied by severedepression. In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and tocooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can giveerroneous conclusions. 9. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hairis dyed pink with black streaks throughout. She has several pierced holes in her nares andears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: a. She probably does not have any problems. b. She is only trying to shock people and thather dress should be ignored. c. She has a manic syndrome because of herabnormal dress and grooming. d. More information should be gathered todecide whether her dress is appropriate. 82 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Grooming and hygiene should be noted—the person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beardsor moustaches are well groomed. Care should be taken when interpreting clothing that isdisheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend. 10. A patient has been in the intensive care unit for 10 days. He has just been moved to themedical-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. May display some disruption in thoughtcontent. b. Will state, “I am so relieved to be out ofintensive care.” c. Will be oriented to place and person, but 83 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness. The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, “Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items. 11. During a mental status examination, the nurse wants to assess a patient’s affect. The nurseshould ask the patient which question? a. “How do you feel today?” b. “Would you please repeat the followingwords?” c. “Have these medications had any effect onyour pain?” d. “Has this pain affected your ability to get dressed by yourself?” Judge mood and affect by body language and facial expression and by directly asking, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should appropriately change with thetopics. 12. The nurse is planning to assess new memory with a patient. The best way for the nurse todo this would be to: 84 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic. Ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four UnrelatedWords Test tests the person’s ability to lay down new memories and is a highly sensitiveand valid memory test. 13. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not four unrelated words . 85 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Invent; within 5 minutes b. Invent; within 30 seconds c. Recall; after a 30-minute delay d. Recall; after a 60-minute delay The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, “I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay. 14. During a mental status assessment, which question by the nurse would best assess aperson’s judgment? a. “Do you feel that you are being watched,followed, or controlled?” b. “Tell me what you plan to do once you aredischarged from the hospital.” c. “What does the statement, ‘People in glasshouses shouldn’t throw stones,’ mean to you?” d. “What would you do if you found a stamped, addressed envelope lying on thesidewalk?” A person exercises judgment when he or she can compare and evaluate the alternatives ina situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (as illustrated in the option with the 86 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 envelope), the nurse should be more interested in the person’s judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior. 15. Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode ofmajor depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like tokill herself d. Older adult man who tells the nurse thathe is going to “join his wife in heaven” 87 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 tomorrow and plans to use a gun When the person expresses feelings of sadness, hopelessness, despair, or grief, assessingany possible risk of physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or sheshould continue with more specific questions. A precise suicide plan to take place in thenext 24 to 48 hours with use of a lethal method constitutes high risk. 16. The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter.Which action or statement might lead the nurse to be concerned about the girl’s mental status? a. She clings to her mother whenever thenurse is in the room. b. She appears angry and will not make eyecontact with the nurse. c. Her mother states that she has begun toride a tricycle around their yard. d. Her mother states that her daughter prefersto play with toddlers instead of kids her own age while in daycare. The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, the nurse should follow the same Association for Behavioral and Cognitive Therapies (ABCT) guidelines as those for the adult, with special consideration for developmental milestones. The best examination technique arises froma thorough knowledge of the developmental milestones (described in Chapter 2). 88 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected). 17. The nurse is assessing orientation in a 79-year-old patient. Which of these responseswould lead the nurse to conclude that this patient is oriented? a. “I know my name is John. I couldn’t tell you where I am. I think it is 2010, though.” b. “I know my name is John, but to tell you the truth, I get kind of confused about thedate.” c. “I know my name is John; I guess I’m at the hospital in Spokane. No, I don’t know the date.” 89 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 d. “I know my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010.” Many aging persons experience social isolation, loss of structure without a job, a changein residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town. 18. The nurse is performing the Denver II screening test on a 12-month-old infant during aroutine well-child visit. The nurse should tell the infant’s parents that the Denver II: a. Tests three areas of development: cognitive, physical, and psychological b. Will indicate whether the child has a speech disorder so that treatment canbegin. c. Is a screening instrument designed todetect children who are slow in development. d. Is a test to determine intellectual ability and may indicate whether problems willdevelop later in school. The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motoradaptive, and personal-social. The Denver II is not an intelligence test; it does not 90 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 predictcurrent or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens. 19. A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The bestdescription of this patient’s level of consciousness would be: a. Lethargic b. Obtunded c. Stuporous d. Semialert Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not 91 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. (See Table 5-3 for the definitions of the other terms.) 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 mytrain.” What is the best description of this patient’s problem? a. Global aphasia b. Broca’s aphasia c. Echolalia d. Wernicke’s aphasia This type of communication illustrates Wernicke’s or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent,effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person’s words or phrases. (See Table 5-4 for the definitions of theother disorders.) 21. A patient repeatedly seems to have difficulty coming up with a word. He says, “I was onmy way to work, and when I got there, the thing that you step into that goes up in the airwas so full that I decided to take the stairs.” The nurse will note on his chart that he is using or experiencing: a. Blocking 92 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 b. Neologism c. Circumlocution d. Circumstantiality Circumlocution is a roundabout expression, substituting a phrase when one cannot thinkof the name of the object. 22. During an examination, the nurse notes that a patient is exhibiting flight of ideas. Whichstatement by the patient is an example of flight of ideas? a. “My stomach hurts. Hurts, spurts, burts.” b. “Kiss, wood, reading, ducks, onto, maybe.” c. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s 93 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 bottom.” d. “I wash my hands, wash them, wash them.I usually go to the sink and wash my hands.” Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizableassociations or are plays on words. PTS: 1 REF: p. 84 DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity 23. A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has madean effort to identify all the places he might encounter a snake and avoids them. The nurserecognizes that he: a. Has a snake phobia. b. Is a hypochondriac; snakes are usually harmless. c. Has an obsession with snakes. d. Has a delusion that snakes are harmful, which must stem from an early traumaticincident involving snakes. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. (See Table 5-7 for the definitions of the other terms.) 94 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 24. A patient has been diagnosed with schizophrenia. During a recent interview, he shows thenurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect An inappropriate affect is an affect clearly discordant with the content of the person’s speech. (See Table 5-5 for the definitions of the other terms.) 25. During reporting, the nurse hears that a patient is experiencing hallucinations. Which isan example of a hallucination? a. Man believes that his dead wife is talking 95 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 to him. b. Woman hears the doorbell ring and goesto answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only adry cleaning bag. d. Man believes that the dog has curled upon the bed, but when he gets closer he sees that it is a blanket. Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory. 26. A 20-year-old construction worker has been brought into the emergency department withheat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient’s: a. Affect and mood b. Memory and affect c. Language abilities d. Level of consciousness and cognitive abilities Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not analteration in mood, affect, or language abilities. 96 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 27. A patient states, “I feel so sad all of the time. I can’t feel happy even doing things I usedto like to do.” He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? a. “Have you had any weight changes?” b. “Are you having any thoughts of suicide?” c. “How long have you been feeling this way?” d. “Are you having feelings of worthlessness?” Major depressive disorder is characterized by one or more major depressive episodes, that is, at least 2 weeks of depressed mood or loss of interest accompanied by at least fouradditional symptoms of depression. Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive 97 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 symptoms. 28. A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinictoday for a follow-up assessment. The nurse will want to ask her which one of these questions? a. “How are things going with the trial?” b. “How are things going with your job?” c. “Tell me about your recent engagement!” d. “Are you having any disturbing dreams?” In posttraumatic stress disorder, the person has been exposed to a traumatic event. Thetraumatic event is persistently reexperienced by recurrent and intrusive, distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring. 29. The nurse is performing a mental status examination. Which statement is true regardingthe assessment of mental status? a. Mental status assessment diagnosesspecific psychiatric disorders. b. Mental disorders occur in response toeveryday life stressors. c. Mental status functioning is inferred through the assessment of an individual’sbehaviors. 98 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 d. Mental status can be directly assessed, similar to other systems of the body (e.g.,heart sounds, breath sounds). Mental status functioning is inferred through the assessment of an individual’s behaviors.It cannot be directly assessed like the characteristics of the skin or heart sounds. 30. A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? a. “How do you usually feel? Is this normal behavior for you?” b. “I am going to say four words. In a few minutes, I will ask you to recall them.” c. “Describe the meaning of the phrase, ‘Looking through rose-colored glasses.’” 99 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 d. “Pick up the pencil in your left hand, move it to your right hand, and place it onthe table.” Attention span is evaluated by assessing the individual’s ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span. 31. The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is mostimportant to use when assessing mental status in this patient? a. “Please count backward from 100 byseven.” b. “I will name three items and ask you torepeat them in a few minutes.” c. “Please point to articles in the room andparts of the body as I name them.” d. “What would you do if you found a stamped, addressed envelope on thesidewalk?” Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the personto read available print), and writing (asking the person to make up and write a sentence). 32. A 30-year-old female patient is describing feelings of hopelessness and depression. Shehas attempted self-mutilation and has a history of suicide attempts. She describes 100 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse’s best response in this situation? a. “Do you have a weapon?” b. “How do other people treat you?” c. “Are you feeling so hopeless that you feellike hurting yourself now?” d. “People often feel hopeless, but the feelings resolve within a few weeks.” When the person expresses feelings of hopelessness, despair, or grief, assessing the riskof physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions. 33. The nurse is providing instructions to newly hired graduates for the mini–mental state 101 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 examination (MMSE). Which statement best describes this examination? a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiatethese from psychiatric mental illness. d. The MMSE is useful tool for an initial evaluation of mental status. Additionaltools are needed to evaluate cognition changes over time. The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate thesefrom 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 orsounds. This finding reflects which type of aphasia? a. Global b. Broca’s c. Dysphonic d. Wernicke’s 102 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 Global aphasia is the most common and severe form of aphasia. Spontaneous speech isabsent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. (Broca’s aphasia and Wernicke’s aphasia are described in Table 5-4.)Dysphonic aphasia is not a valid condition. 35. A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” The nurse documents thisas an illustration of: a. Blocking b. Clanging c. Echolalia d. Neologism Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. (See Table 5-6 for the definitions of the other terms.) 103 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 36. During an interview, the nurse notes that the patient gets up several times to wash herhands even though they are not dirty. This behavior is an example of: a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducingdistress or preventing some dreaded event or situation. 37. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of orderand with an incorrect time. This result indicates which finding? a. Cognitive impairment b. Amnesia c. Delirium d. Attention-deficit disorder The Mini-Cog is a newer instrument that screens for cognitive impairment, often foundwith dementia. The result of an abnormal drawing of a clock and time indicates 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 speechpattern is an example of: 104 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 a. Echolalia b. Clanging c. Word salad d. Perseveration Echolalia occurs when a person imitates or repeats another’s words or phrases, often witha mumbling, mocking, or a mechanical tone. MULTIPLE RESPONSE 1. The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. a. Develops over a short period. b. Person is experiencing apraxia. 105 NURSING 2058 Health Assessment Exam1: Study Guide UPDATED 2025/2026 c. Person is exhibiting memory impairmentor deficits. d. Occurs as a result of a medical condition, such as systemic infection. e. Person is experiencing agnosia. Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.