Health Assessment

65. A nursing instructor is discussing techniques used in the inspection of a patient. What would the instructor list as necessary or important when inspecting a patient? A) Adequate exposure B) Dim lighting C) Therapeutic touch D) Therapeutic communication

A) Adequate exposure

129. A 52-year-old woman comes to the clinic reporting pain in her right lower quadrant. When assessing the patient's pain, what elements would the nurse include? (Mark all that apply.) A) Aggressiveness B) Intensity C) Quality D) Functional goal E) Quantity

A) Aggressiveness B) Intensity C) Quality D) Functional goal

19. A clinical instructor is teaching a group about organizing data when documenting and communicating findings. The clinical instructor knows that the method she is teaching promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? A) Body systems B) Comprehensive C) Head to toe D) Functional

A) Body systems

128. What is an excitatory process caused by pain stimuli that involves the spinal nerves and can persist when there is no longer stimulation? A) Central sensitization B) Neuronal windup C) Peripheral sensitization D) Neuronal plasticity

A) Central sensitization

134. When a patient with opioid tolerance has an altered physiologic response to pain stimuli, he or she develops a form of pain sensitivity called what? A) Opioid hyperalgesia B) Pain hyperactivity C) Opioid hypoalgesia D) Pain hypoactivity

A) Opioid hyperalgesia

39. When a patient responds to a question with a "yes" or "no" answer, what appropriate responses by the nurse encourage the patient to elaborate? (Select all that apply.) A) Yes B) I see C) Um hum D) Go on E) Okay

A) Yes B) I see D) Go on

69. Nursing students are in the laboratory practicing palpation. What would they learn about the best depth for moderate palpation? A) ½ to 1 cm B) 1 to 2 cm C) 1 to 2½ cm D) 2 to 3 cm

B) 1 to 2 cm

40. How does a nurse indicate to patients that their concerns are not worth discussing? A) By being empathetic B) By providing false reassurance C) By being sympathetic D) By giving unwanted advice

B) By providing false reassurance

3. The purpose of a health assessment includes what? (Select all that apply.) A) Identifying the patient's major disease process B) Collecting information about the health status of the patient C) Clarifying the patient's ability to pay for health care D) Evaluating patient outcomes E) Synthesizing collected data

B) Collecting information about the health status of the patient D) Evaluating patient outcomes E) Synthesizing collected data

A 13 year old patient with cancer asks the nurse what hair is made of. What would be the nurses best answer A. Hair consist mostly of carbohydrates B. Hair consist mostly of protein C. Hair consists mostly of inorganic matter D. Hair consists mostly of cellular waste

B. Hair consists mostly of protein

31. A nurse is performing an admission assessment on a patient new to the unit. What would be the best way to phrase a question about the patient's marital status? A) "Is your spouse living with you?" B) "Are you living with your spouse?" C) "Do you live alone or with someone?" D) "Are you married, divorced, or widowed?"

C) "Do you live alone or with someone?"

53. The nurse is caring for an 82-year-old man and is reviewing information obtained in the health history assessment. The nurse knows that it is important to identify the pattern of illnesses and recognize how they might be related because this patient is what? A) In the hospital B) Stoic C) An older adult D) Chronically ill

C) An older adult

13. A nurse performs a comprehensive assessment on a patient. What is included in this assessment? A) Circulatory assessment B) Assessment of the airway C) Complete health history D) Disability assessment

C) Complete health history

6. How do nurses facilitate the achievement of high-level wellness with a patient? A) Encouraging the patient to keep appointments B) Providing information on alternative treatments C) Promoting health D) Providing good patient care

C) Promoting health

28. During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions? A) Preinteraction B) Beginning C) Working D) Ending

C) Working

124. Both the peripheral and the central nervous systems are involved in the transmission of a pain stimulus. When there is continued input from the peripheral nervous system, what can develop? A) Fibromyalgia B) A peripherally mediated pain syndrome C) Neuronal plasticity D) A centrally mediated pain syndrome

D) A centrally mediated pain syndrome

15. A nurse is admitting a patient, has completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data? A) Concrete B) Subjective C) Realistic D) Objective

D) Objective

137. What is the best description of the pain phenomena felt in rheumatoid arthritis and osteoarthritis? A) Neuronal windup B) Neuronal plasticity C) Peripheral sensitization D) Central sensitization

A) Neuronal windup

38. When a nurse conducts an interview with a patient, what is the underlying purpose? A) To provide therapeutic communication when indicated B) To gather subjective information C) To assess the patient's physical status D) To identify the patient's diagnoses

A) To provide therapeutic communication when indicated

88. One of the goals of nursing is to provide care that is safe to patients. What is the best way for nurses to realize this goal? A) By accurately charting patient care B) By continually assessing patient laboratory values C) By continual communication with all members of the health care team D) By giving patient care conferences including all members of the health care team

C) By continual communication with all members of the health care team

131. A pediatric nurse is assessing a 4-week-old boy who has just been admitted to the pediatric unit with a diagnosis of possible pyloric stenosis. When assessing this patient, what behavior would indicate pain in this newborn to the nurse? A) Closed lips B) Extended fingers C) Nasolabial fold D) Eye widening

C) Nasolabial fold

91. When a nurse works in a health care agency that charts by exception (CBE), he or she knows that the patient assessment is structured by what? A) Medical diagnoses B) Patient needs C) Standardized norms D) Joint Commission standards

C) Standardized norms

41. During the interview process, the nurse obtains what type of data from the patient? A) Primary B) Secondary C) Objective D) Oral

A) Primary

36. Patients in health care settings often are anxious. What behaviors would lead a nurse to believe that a patient is anxious? (Select all that apply.) A) Rapid speech B) Crying C) Defensive tone D) Steady voice E) Sweating

A) Rapid speech C) Defensive tone E) Sweating

4. The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? A) How much time the nurse has B) The patient's acuity C) The patient's cooperation D) Onset of current symptoms

B) The patient's acuity

72. A student nurse is spending clinical hours on the medical-surgical unit with an experienced nurse. The student is assessing a patient using indirect percussion. The student hears what sound while percussing the center of the patient's abdomen? A) Resonance B) Tympany C) Dullness D) Damping

B) Tympany

100 HIPAA gives patients greater control over their medical records. What else does HIPAA provide? A) Copying of medical records B) Education of lay people about medical records C) Patient recourse if privacy protections are violated D) Legal use of medical records

C) Patient recourse if privacy protections are violated

54. Through what process do the patient and the nurse work together to develop a plan of care? A) Functional assessment B) Use of subjective and objective data C) Therapeutic communication D) Use of Gordon's framework

C) Therapeutic communication

34. A nurse is interviewing a 76-year-old man who has come to the clinic for the first time. The nurse prioritizes questions for which of the following reasons? A) Older adults know which subjects are most important B) Older adults have longer health histories C) Older adults take more medications D) Older adults tire more easily

D) Older adults tire more easily

61. What tool does the nurse use to auscultate the patient's abdomen? A) None B) Fetoscope C) Sonoscope D) Stethoscope

D) Stethoscope

89. A new graduate nurse has just started working. The new nurse asks a more experienced nurse to explain SOAP charting. What would the second nurse explain that the A in SOAP stands for? A) Analysis of data to identify a problem B) Assessment of subjective data C) Assessment of objective data D) Articulation of the plan of treatment

A) Analysis of data to identify a problem

93. Nursing students are learning about different methods of charting in the clinical laboratory. What method would they learn that is a shared mental model for improving communication between and among clinicians? A) SBAR B) CBE C) SOAP D) PIE

A) SBAR

138. The nurse is assessing the pain of an 86-year-old man who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain? A) Sleep patterns B) Family history C) Genetic history D) Elimination pattern

A) Sleep patterns

123. The element of pain transmission that causes nociceptors to perceive a nerve impulse is what? A) Transduction B) Transmission C) Perception D) Modulation

A) Transduction

A 78 year old man has been hospitalized with a broken right hip. The nurse assesses the patient, finds signs of malnutrition and consults the dietician. While reinforcing the dieticians teaching about primary nutrients and their role in maintaining health to the patient and his family, the nurse describes complex carbohydrates as what? A. Polysaccharides B. Monosaccharides C. Phospholipids D. Carbosaccharides

A. Polysaccharides

44. Student nurses are practicing taking comprehensive health histories from one another. What components should be included in a comprehensive health history? (Select all that apply.) A) When coughing began B) Pain location C) Pain duration D) Pain intensity E) What was eaten for breakfast

B) Pain location C) Pain duration D) Pain intensity

21. A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what? A) Humorous B) Uncaring C) Relaxed D) Detached

C) Relaxed

5. A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? A) To establish a database against which subsequent assessments can be measured B) To establish rapport with the patient and family C) To gather information for specialists to whom the patient might be referred D) To quantify the degree of pain a patient may be experiencing

A) To establish a database against which subsequent assessments can be measured

32. A pediatric nurse is working in a community health clinic and seeing a 6-year-old boy. What is the most appropriate way to address this child and his parents? A) Call the child by his legal name and refer to the parents as Mr. and Mrs. B) Call the child by his first name and ask the parents how they prefer to be addressed C) Call the child by his first name and refer to the parents as Mr. and Mrs. D) Call the child by his full name and refer to the parents as "mom" and "dad"

B) Call the child by his first name and ask the parents how they prefer to be addressed

42. The nurse is admitting a new patient to the unit. While reviewing old records of this patient, the nurse knows that the data being gathered are what kind of data? A) Primary B) Secondary C) Subjective D) Objective

B) Secondary

115. General survey of a 27-year-old woman reveals that the patient is wearing eccentric makeup and clothes. For what would the nurse perform further assessments? A) Inadequate finances B) Depression C) Poor hygiene D) Mania

D) Mania

70. When percussing a patient, where would the nurse expect to find the loudest tones? A) Over the liver B) Over the bladder C) Over the spleen D) Over the lungs

D) Over the lungs

30. A patient who only speaks Spanish is admitted to the unit. The patient's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this patient? A) The sister may not tell the patient exactly what the nurse says B) The patient's sister may not understand medical terminology C) The sister may not be there every time the nurse needs to talk to the patient D) The patient may not want her sister to know her private information

D) The patient may not want her sister to know her private information

27. A nurse is preparing to admit a new patient to the unit and is reviewing the patient record chronologically. In what phase of the interview process are the nurse and the patient? A) Preinteraction B) Beginning C) Working D) Ending

A) Preinteraction

86. A clinical instructor is discussing with students the care provided to a patient. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer? A) To have up-to-date information on which to base clinical decisions B) To be able to verify what care has been given C) To communicate with other health care providers D) To be able to update the plan of care

A) To have up-to-date information on which to base clinical decisions

139. A 78-year-old patient is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults? A) Older adults have fewer nerve fibers; therefore, they feel less pain B) Older adults may be reluctant to report pain C) Older adults are always in chronic pain D) Older adults are stoic and expect to be in pain

B) Older adults may be reluctant to report pain

99. To make a legal entry into the medical record, the nurse must document what? A) Laboratory tests ordered B) Attending physician C) Time of the assessment D) Nature of the assessment

C) Time of the assessment

103. What is the importance of assessing vital signs? (Mark all that apply.) A) To identify pending problems B) To plan how to improve a patient's condition C) To establish a baseline D) To monitor risks for alterations in health E) To evaluate the patient's responses to treatment

C) To establish a baseline D) To monitor risks for alterations in health E) To evaluate the patient's responses to treatment

9. A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse use? A) Rationale B) ANA recommendations C) Physical assessment skills D) Diagnostic reasoning

D) Diagnostic reasoning

37. Nurses weave the individualization of the patient interview through all aspects of the encounter. The nurse should avoid assuming that patients follow cultural beliefs. In place of making this assumption, what should a nurse do? A) Assess the degree to which the patient perceives the cultural beliefs B) Assess how acculturated the patient is C) Know the mores of the culture D) Know his or her own cultural beliefs

A) Assess the degree to which the patient perceives the cultural belief

119. The nurse is performing assessments on several male patients. The first one is 52 years old and African American. The second one is 54 years old and Mexican American. The third one is 50 years old and Native American. The fourth one is 60 years old and Caucasian. Which patient would the nurse expect to be tallest? A) Caucasian B) African American C) Mexican American D) Native American

A) Caucasian

95. What is the most common use of SBAR? A) Contacting a provider regarding a patient issue B) Structuring communications during handoff C) Delegating care to nursing assistants D) Expressing concern about a patient's condition to the charge nurse

A) Contacting a provider regarding a patient issue

43. The nursing instructor is discussing with students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer? (Select all that apply.) A) During a hospital admission B) At a clinic visit for a fall C) In the emergency department after a car accident D) During an annual physical examination E) At a screening for sports participation

A) During a hospital admission D) During an annual physical examination E) At a screening for sports participation

107. A 39-year-old man is at the gym exercising and develops a pain in his upper right quadrant. The paramedics are called; their initial vital-sign readings indicate a pulse of 175 beats/min. This pulse would be considered what? (Mark all that apply.) A) Elevated due to pain B) Elevated due to age C) Elevated due to gender D) Elevated due to activity E) Elevated due to weight

A) Elevated due to pain D) Elevated due to activity

46. A clinical instructor is discussing with a clinical group how to take a history of the patient's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer? A) Follow the cues of the patient during the interview B) Use a written checklist to make sure you cover all necessary areas C) Use a head-to-toe approach to make sure you do not miss anything D) Use a focused approach, asking only about symptoms of the present illness

A) Follow the cues of the patient during the interview

81. The medical record serves many purposes. What are they? (Select all that apply.) A) Framework for medical information B) Means for financial reimbursement C) Research D) Care planning E) Information for the family

A) Framework for medical information B) Means for financial reimbursement C) Research D) Care planning

16. The nurse is performing a health assessment on a new patient. While taking the detailed history, the nurse knows to include what? A) Functional status B) Only data involving the patient complaint C) A focused assessment of the patient complaint D) Family history for the past three generations

A) Functional status

76. When assessing a patient, the first skill used is inspection. What purpose does inspection serve? A) Gathering information B) Feeling abnormalities C) Observing modesty D) Identifying internal abnormalities

A) Gathering information

108. A 68-year-old woman with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the patient to an examination room and measures vital signs. The nurse would expect the patient's vital signs to be what? A) Higher than normal B) Lower than normal C) WNL D) The nurse would not routinely take this patient's vital signs

A) Higher than normal

68. For what is light palpation appropriate? (Select all that apply.) A) Inflamed areas of skin B) Internal organs C) Skin texture D) Deep pain E) Surface lesions

A) Inflamed areas of skin C) Skin texture E) Surface lesions

132. A 5-year-old girl is admitted to the postanesthesia care unit after the repair of her fractured femur. What activities would best indicate pain in this child according to the FLACC scale? (Mark all that apply.) A) Leg movement B) Arched back C) Sleep D) Eye widening E) Difficulty consoling

A) Leg movement B) Arched back D) Eye widening E) Difficulty consoling

78. A nurse in the emergency department is assessing a patient admitted with suspected appendicitis. What type of palpation over the right lower quadrant of this patient would the nurse use? A) None B) Light palpation C) Deep palpation D) Moderate palpation

A) None

112. A nurse is caring for a 36-year-old woman with a temperature of 38.9°C. The nurse administers Tylenol, 2 tablets, as per orders. What is the most correct place in which to record the effect of the medication administration on the patient's temperature? A) Nurse's notes B) Vital sign flow sheet C) Progress notes D) MAR

A) Nurse's notes

11. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? A) Nursing process B) Diagnostic reasoning C) Critical thinking D) Community care map

A) Nursing process

116. Student nurses are doing clinical hours on the medical-surgical unit. What additional assessment should the student nurses make when they take patient vital signs? A) Oxygen saturation B) Blood pressure C) Heart rate D) Mobility

A) Oxygen saturation

33. A clinic nurse is caring for a newborn and her parents. Observing parental behavior is an important nursing function during this child's well-baby visit. What would the nurse expect during observation? A) Parents encouraging the baby's happy behaviors B) Parents feeding the baby every time she cries C) Parents ignoring the infant's fussy behavior D) Parents playing with an irritable infant

A) Parents encouraging the baby's happy behaviors

73. When auscultating the patient's lungs, how should the nurse position the earpieces of the stethoscope? A) Pointed toward the nose B) Pointed toward the occiput C) At a 90° angle from the nose D) At a 45° angle to the occiput

A) Pointed toward the nose

79. It is necessary to accurately describe the sounds heard while percussing a patient. When subjectively describing the percussion sound, what is the nurse describing? A) Quality B) Intensity C) Duration D) Pitch

A) Quality

What do nursing activities that promote health and prevent disease accomplish? (Select all that apply.) A)Reduce the risk of disease B)Maintain optimal functioning C)Reinforce good habits D)Optimize self-care abilities E)Create home care safety

A) Reduce the risk of disease B) Maintain optimal functioning C) Reinforce good habits

58. The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as he or she does the assessment. The instructor explains that the use of the mnemonic is to? A) Remember the elements that are important to assess for B) Remember the parts of a focused assessment C) Remember the order of the assessment D) Remember how to document assessment findings

A) Remember the elements that are important to assess for

22. A nurse is admitting a new patient. The patient is lying in bed. Where should the nurse be positioned? A) Seated in a chair at eye level with the patient B) Sitting on the side of the bed, looking down at the patient C) Leaning on the nightstand at eye level with the patient D) Standing beside the bed, looking down at the patient

A) Seated in a chair at eye level with the patient

24. A nurse is interviewing a patient who uses an expression with which the nurse is unfamiliar. What is the most appropriate expression for the nurse to use to clarify the expression's meaning from the patient? A) Tell me what you mean by ________? B) I think that expression means ____________ C) That expression is unclear to me D) Where did you hear that expression?

A) Tell me what you mean by ________?

101. As part of the general survey, the nurse should shake hands with the patient when first meeting him or her as long as doing so is culturally appropriate. Why is this action so important? A) The handshake portrays caring B) The handshake shows how professional the nurse is C) The handshake allows the nurse to get physically close to the patient in a nonthreatening way D) The handshake allows the nurse to assess how nervous the patient is

A) The handshake portrays caring

50. The nurse is caring for a 77-year-old woman who has been admitted with a fractured hip. While doing the admission assessment, the patient states, "I tripped over the small rug we have in front of the sink." What subject would this report indicate that needs teaching during this patient's hospital stay? A) The need to eliminate rugs on the patient's floors B) The need to have wall-to-wall carpeting throughout the patient's house C) The need for the patient to use a walker when she goes into the kitchen D) The need for the patient to be in a wheelchair

A) The need to eliminate rugs on the patient's floors

96. A nurse has assessed that a patient's condition is worsening. The nurse is telephoning the primary care provider and providing an SBAR report about the patient and her condition. What would be important for the nurse to document? (Select all that apply.) A) The time B) Information from the previous shift C) The information received D) Specialists to whom the patient is referred E) The name of the provider

A) The time C) The information received E) The name of the provider

84. Why do nursing students review medical records? (Select all that apply.) A) To enhance clinical learning B) To compare nursing care provided to patients C) To evaluate the plan of care for a specific patient D) To verify that laboratory results are accurate E) To better understand complex clinical situations

A) To enhance clinical learning E) To better understand complex clinical situations

135. What are the steps for pain transmission in the gate control theory? (Mark all that apply.) A) Unrelieved painful stimulus on a peripheral neuron causes the "gate" to open B) The gate opens through repolarization of the nerve fiber C) The brain stem recognizes the stimulus as pain D) The pain stimulus passes down the afferent pathway E) The pain stimulus crosses the dorsal horn of the spine to the limbic system

A) Unrelieved painful stimulus on a peripheral neuron causes the "gate" to open E) The pain stimulus crosses the dorsal horn of the spine to the limbic system

97. A nurse has been called to testify in a lawsuit brought by a patient against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose? A) The charting format is not ethical B) Details are often missing C) Subjective information is often missing D) It reflects poor assessment skills on the part of the nurse

B) Details are often missing

51. After completing the interview process, the nurse analyzes the data collected in order to? A) Establish a baseline from which to start interviewing the family B) Develop nursing interventions C) Communicate information to the physician D) Communicate information to other staff members

B) Develop nursing interventions

105. How does the nurse use critical thinking when accurately assessing vital signs? A) Evaluating assessment techniques B) Developing nursing diagnoses C) Monitoring evaluations D) Planning assessment techniques

B) Developing nursing diagnoses

26. A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic? A) Clarification B) Distraction C) Summarizing D) Focusing

B) Distraction

55. A nurse is assessing a patient and collecting only the most important information. What type of assessment is the nurse doing? A) Functional B) Emergency C) Comprehensive D) Focused

B) Emergency

47. A genogram is developed to visually show what? A) Family tree B) Family health patterns C) Family relationships D) Nationalities of family members

B) Family health patterns

12. What are the types of nursing assessments? (Select all that apply.) A) Physical B) Focused C) Mental D) Emergency E) Comprehensive

B) Focused D) Emergency E) Comprehensive

109. A nurse knows that normal blood pressure A) Stays level throughout the day B) Follows a diurnal rhythm C) Rises with the early morning fall of blood glucose D) Follows the same cycle as the sun

B) Follows a diurnal rhythm

60. A new patient is admitted to the clinic. The nurse assesses how the effects of health or illness affect the patient's quality of life. What type of assessment is this nurse performing? A) Comprehensive B) Functional C) Emergency D) Focused

B) Functional

121. What is the most commonly accepted theory of pain? A) Pain stimulus theory B) Gate control theory C) Pain transmission theory D) Gatekeeper theory

B) Gate control theory

87. The Joint Commission, in 2006, developed a National Patient Safety Goal. What is a requirement of this goal? A) Health care agencies need to standardize their charting B) Health care agencies need to develop a standardized approach to hand off communications C) Health care agencies need to conform to Joint Commission communication templates D) Health care agencies need to computerize medical records

B) Health care agencies need to develop a standardized approach to hand off communications

117. An ICU nurse is caring for a patient in shock. To obtain an accurate set of vital signs, the nurse uses a Doppler to obtain pulse and blood pressure. What would be the best technique for the use of the Doppler on this patient? (Mark all that apply.) A) Hold the probe firmly against the skin at the expected pulse site B) Hold the probe perpendicular to the skin at the expected pulse site C) Use the gel that is on the cart D) Mark the location of the loudest sound E) Move the probe slowly over the area of the expected pulse site

B) Hold the probe perpendicular to the skin at the expected pulse site D) Mark the location of the loudest sound E) Move the probe slowly over the area of the expected pulse site

92. When charting by exception is used in a health care agency, the most important aspect of this method is what? A) Organizing new forms for the nursing staff B) Identifying the standards and norms for the institution C) Training new nurses in writing CBE notes D) Pulling together a group of experts to teach agency staff

B) Identifying the standards and norms for the institution

98. How does computerized documentation enhance communication? (Select all that apply.) A) It is more complete than handwritten charting B) It is legible and time dated C) It permits multiple simultaneous users D) It increases compliance E) It verifies telephone communication

B) It is legible and time dated C) It permits multiple simultaneous users D) It increases compliance

63. What steps are involved in the patient-to-patient transmission of pathogens? (Select all that apply.) A) The nurse uses an alcohol-based hand rub for hand hygiene B) Organisms are transferred from the patient to the nurse's hands C) Organisms survive on the nurse's hands for less than 1 minute D) The nurse's contaminated hands come into direct contact with another patient E) Organisms are present in the patient's immediate environment

B) Organisms are transferred from the patient to the nurse's hands D) The nurse's contaminated hands come into direct contact with another patient E) Organisms are present in the patient's immediate environment

126. A nurse is caring for a patient who reports constant pain. The nurse knows that constant pain can lead to the modification of the function of the nervous system, which can, in turn, lead to what? A) Neuronal windup B) Peripheral sensitization C) Neuronal plasticity D) Chronic pain

B) Peripheral sensitization

17. What does the Health Insurance Portability and Accountability Act (HIPAA, 2002) regulate? A) Who empties the hospital waste B) Privacy of information C) How insurance information is obtained D) Where a chart can be stored

B) Privacy of information

23. A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows patients to what? A) Rest and improve health B) Provide accurate answers C) Talk about their feelings D) Communicate verbal concern

B) Provide accurate answers

102. The nurse is caring for a newly admitted adult patient. When performing the general survey of this patient, the nurse knows that accurate measurements provide critical information about what? A) Safety B) State of health C) Growth pattern D) Past surgeries

B) State of health

7. The nurse is caring for a patient who, on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true? A) The patient stops doing wellness-promoting activities B) The patient develops signs and symptoms C) The patient begins exercising D) The patient verbalizes anxiety over the cost of medications

B) The patient develops signs and symptoms

113. While assessing respirations and heart rate in an 8-year-old patient, the nurse finds that the patient's heart rate increases during inspiration and decreases during expiration. What would be the most correct way to document this finding? A) The patient has an abnormal heart rate B) The patient has a sinus arrhythmia C) The patient's heart rate speeds up and slows down in a cyclical pattern D) The patient has a cardiopulmonary disorder

B) The patient has a sinus arrhythmia

136. The Joint Commission mandates that nurses assess and reassess a patient's pain level. A nurse's institution mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what? A) Research that shows that it takes half as long for IV pain medication to work than oral medication B) The time it takes a pain medication to decrease pain intensity C) The time it takes a pain medication to block pain in a patient D) The median half-life of an intravenous pain medication

B) The time it takes a pain medication to decrease pain intensity

82. A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? A) To provide a record of the nurse's activities B) To provide a record of the actual events C) To provide a record of how the patient was harmed D) To provide a record of the physician's activities

B) To provide a record of the actual events

64. According to the 2009 guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.) A) To help maintain a sterile environment B) To reduce transient contamination of the hands C) To reduce the risk of infecting personnel D) To prevent the transmission of bacteria from nurses to patients E) To reduce the number of bacteria in the health care environment

B) To reduce transient contamination of the hands C) To reduce the risk of infecting personnel D) To prevent the transmission of bacteria from nurses to patients

130. The nurse is assessing a 17-year-old boy with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this patient? A) Gathering information that the patient wants to share about his pain B) Using in-depth questions to collect salient data about the patient's pain C) Collecting objective data that the patient chooses to share D) Collecting subjective data that the nurse notes during assessment

B) Using in-depth questions to collect salient data about the patient's pain

114. A nurse is admitting a new patient who is scheduled to have a five-vessel cardiac bypass in the morning. Assessment reveals that the patient is very anxious. The nurse's aide reports that the patient's vital signs are elevated. How would the nurse document these findings in the patient's care plan? A) Anxiety as evidenced by patient's verbalizations B) Abnormal temperature as evidenced by vital sign assessment C) Anxiety as evidenced by increased heart rate and pulse D) Cardiac status stable as evidenced by electrocardiogram WNL

C) Anxiety as evidenced by increased heart rate and pulse

45. The nurse is gathering a complete history of the patient's present illness. The nurse knows that the most appropriate way to begin to gather this information is what? A) Assessing the patient's vital signs B) Gathering a complete list of the patient's medications C) Asking open-ended questions D) Asking focused questions

C) Asking open-ended questions

35. When dealing with a patient who has impaired hearing, where would the nurse sit to facilitate lip reading? A) Halfway across the room from the patient B) Next to patient on the side from which he or she hears best C) Closer to the patient than the nurse normally would D) Knee to knee directly in front of the patient

C) Closer to the patient than the nurse normally would

94. The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. What would the instructor explain that the situation, background, and assessment are based on in SBAR charting? A) The patient's background B) Information that the nurse obtains from the family C) Complete and accurate assessment data D) Data in old records

C) Complete and accurate assessment data

127. Pain is often untreated or undertreated; when this occurs, chronic pain may result. What can be the outcome? A) Chronic sensitization syndrome B) Peripheral sensitization syndrome C) Complex regional pain syndrome D) Fibromyalgia pain syndrome

C) Complex regional pain syndrome

10. A nurse is caring for three patients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse? A) Diagnostic reasoning B) Physical assessment C) Critical thinking D) Nursing care plan

C) Critical thinking

56. A student is working with a floor nurse who is admitting a new patient to the unit. The nurse asks the patient if he has traveled outside the United States in the past 12 months. The student knows that this information is part of what area of the comprehensive health history? A) Activities B) Present illness C) Demographical data D) History of illnesses

C) Demographical data

71. A patient presents at the clinic complaining of a possible sinus infection. How would the nurse assess the sinuses in this patient? A) Indirect percussion B) Palpation C) Direct percussion D) Auscultation

C) Direct percussion

122. On what does current research on pain focus? A) Elements that can affect the intensity of pain B) Stopping the cause of pain C) Elements that can affect pain inhibition D) Stopping the sensation of pain

C) Elements that can affect pain inhibition

18. The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the patient. The students know that this type of information is assessed in what type of assessment? A) Body systems B) Head to toe C) Functional D) Comprehensive

C) Functional

48. A group of student nurses is presenting information on Gordon's framework for assessing a patient. What type of assessment would they be talking about? A) Comprehensive B) Focused C) Functional D) Emergency

C) Functional

62. When caring for patients in any health care environment, what is the most important technique for preventing infection? A) Sterile technique B) Standard precautions C) Hand hygiene D) Use of gloves

C) Hand hygiene

8. A nursing instructor is discussing the health belief model with students. What elements would the instructor explain as part of the health belief model? (Select all that apply.) A) Vector B) Chronicity C) Host D) Agent E) Environment

C) Host D) Agent E) Environment

67. A new graduate nurse is inspecting a patient. What is a challenge this nurse will face? A) Maintaining patient modesty B) Learning how to perform inspection C) Identifying subtle differences D) Documenting what is normal

C) Identifying subtle differences

75. Student nurses are in the laboratory learning auscultation techniques. How would they learn to hold the chestpiece on the patient? A) Place the endpiece between the thumb and the index finger B) Place the index and middle fingers on top of the stethoscope C) Place the endpiece between the index and the middle fingers D) Place the thumb and index finger on top of the stethoscope

C) Place the endpiece between the index and the middle fingers

10. A student nurse studying hypertension would learn that the risk factors for it include what? A) Family history, obesity, alcohol abstinence B) Cigarette smoking, heavy alcohol consumption, hepatic disease C) Prolonged stress, renal disease, heavy alcohol consumption D) High cholesterol and triglyceride levels, family history, hepatic disease

C) Prolonged stress, renal disease, heavy alcohol consumption

125. The nursing instructor is discussing the different types of pain with the nursing class. What type of pain would the instructor explain to the students that originates from a specific site, yet the patient feels the pain at another site? A) Chronic pain B) Cutaneous pain C) Referred pain D) Somatic pain

C) Referred pain

57. Why is it important for the nurse to reconcile all the hospitalized patient's medication lists with the medication that the patient regularly takes at home? A) So the physician can order the correct drugs for the hospitalized patient B) So the patient's medication record correlates with the patient's medication history C) So the patient continues taking the correct drugs D) So the physician can make sure to change the patient's drugs

C) So the patient continues taking the correct drugs

25. The patient tells the nurse that he is sorry he fell off the roof and broke his leg. The nurse responds by saying, "Oh, you poor thing! I am sorry you fell off the roof and broke your leg, too." What type of response is this? A) Empathetic B) Therapeutic C) Sympathetic D) Supportive

C) Sympathetic

106. A patient arrives at the emergency department by ambulance after an accident while playing softball. His left leg is swollen and deformed. He describes his pain as a 9 on a 10-point scale. When the nurse assesses the patient's blood pressure, what would he or she expect to find? A) The blood pressure is lower than normal B) There would be no need to assess the blood pressure C) The blood pressure is elevated D) The blood pressure is within normal limits

C) The blood pressure is elevated

83. Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit? A) The evaluation of financial reimbursement B) The evaluation of patient nutrition C) The evaluation of care for continual improvement D) The evaluation of timely documentation of pain

C) The evaluation of care for continual improvement

77. The clinical instructor is discussing a patient with a student nurse. The instructor asks the student why she used percussion on the patient. What would be the student's most accurate response? A) To identify abnormalities B) To hear bowel sounds C) To elicit tenderness D) To produce tympany

C) To elicit tenderness

52. The nursing instructor is explaining to students the difference between the language used when a nurse talks to the patient and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record? A) Document according to the orders of the physician B) Talk to the patient and document exactly the same C) Use medical terminology when documenting in the medical record D) Document exactly as the patient talks

C) Use medical terminology when documenting in the medical record

118. The nurse is caring for four patients on the short-stay unit. Which patient would cause the nurse greatest concern? A) A 10-year-old patient with a BP of 103/62 B) A 7-year-old patient with a sinus dysrhythmia C) A 77-year-old patient with a resting heart rate of 69 beats/min D) An 82-year-old patient with a temperature of 37.2°C

D) An 82-year-old patient with a temperature of 37.2°C

133. A nurse in the emergency department is caring for a patient who is nonverbal following a traumatic injury. What would be the best way for the nurse to assess this patient's level of pain? A) Ask the patient to draw a picture of the pain B) Ask the paramedics what they think is the patient's pain level C) Ask the patient to describe the pain D) Ask the family if they have noticed any changes in the patient's behavior

D) Ask the family if they have noticed any changes in the patient's behavior

49. When using Gordon's framework for a functional health assessment, the nurse asks a patient, "Have you made any changes in your environment because of vision, hearing, or memory decrease?" What functional health pattern is the nurse assessing? A) Vision B) Hearing C) Coping D) Cognition

D) Cognition

29. The nurse is interviewing a patient from a culture different from that of the nurse. The nurse works to preserve the code of conduct that shows respect for others. What is this code of conduct called? A) Good manners B) Direct communication C) Nonverbal communication D) Communication etiquette

D) Communication etiquette

59. While admitting a patient to the unit, the patient states, "I am allergic to sulfa drugs." How would the nurse verify this information? A) Ask family members B) Ask the physician C) Ask the patient about the response to the allergen D) Compare against the patient's legal records

D) Compare against the patient's legal records

90. When an agency has policies that require nurses to write focus notes, the nursing documentation can include what? A) Areas of personal accomplishments B) Areas of personal weakness C) Social networks D) Family concerns

D) Family concerns

111. A nurse is teaching a class on hypertension at the local Chamber of Commerce meeting. What risk factor would the nurse be sure to address to the class? A) Quitting cigarette smoking 5 years ago B) Loss of 50 pounds within the last 12 months C) High cholesterol and low triglyceride levels D) Family history

D) Family history

20. A 26-year-old male nurse is assessing a 14-year-old girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the patient is what? A) Body systems B) Functional C) Focused D) Head to toe

D) Head to toe

14. The nurse is admitting a patient to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? A) Covers the body head to toe B) Occurs only in the clinic area C) Involves all body systems D) Is more in-depth on specific issues

D) Is more in-depth on specific issues

104. The nurse's aide reports to the nurse that a 98-year-old patient has abnormal vital signs. What is important to remember in this type of situation? A) At this patient's age, abnormal vital signs are an indication of something serious B) Normal readings get lower with advanced age C) Normal readings get higher with advanced age D) Normal readings vary according to age

D) Normal readings vary according to age

85. The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? A) Safety among patient populations decreases B) Pharmacy orders are electronically verified C) Physician notes are more secure D) Patient safety increases

D) Patient safety increases

66. The nurse is assessing a patient who is new to the unit. During inspection of the patient, what will the nurse do? A) Tell the patient that modesty is not necessary B) Make sure that the patient is covered C) Look for internal abnormalities D) Smell for odors

D) Smell for odors

74. While beginning assessment of a patient's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact? A) The bell B) The small side of the chestpiece C) The earpieces D) The diaphragm

D) The diaphragm

1. What is one of the broad goals within nursing? A) To prevent mental health B) To form broad nursing diagnoses C) To promote self-care D) To treat human responses

D) To treat human responses