Ch. 1: Introduction to Health Assessment, Ch. 2: Obtaining a Health History, Ch. 3: Techniques and Equipment for Physical Assessment, Ch. 4: General Inspection and Measurement of Vital Signs, Ch. 5: Cultural Assessment, Ch. 6: Pain Assessment, Ch. 7:...

A patient is admitted to the medical-surgical unit with a diagnosis of hypertension. The nurse is using the nursing process to develop the plan of care. Which steps should the nurse incorporate? A. Assessment, treatment, planning, evaluation, discharge, follow-up B. Admission, assessment, diagnosis, treatment, discharge planning C. Admission, diagnosis, treatment, evaluation, discharge planning D. Assessment, diagnosis, outcome identification, planning, implementation, evaluation

D

An insufficient amount of the neurotransmitter GABA may result in __. A. depression B. hallucinations C. delusions D. anxiety

D

The __ refers to the circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to physical, psychologic, or socioeconomic circumstances involving patients, or the expertise of the nurse. A. body systems assessment B. nursing process C. health promotion interventions D. context of care

D

The nurse is assessing a patient for the first time in the outpatient diabetic clinic. A __ type of health assessment would be most appropriate for this visit. A. focused assessment B. episodic follow-up assessment C. shift assessment D. comprehensive health assessment

D

The nurse is assessing a patient's activity level. Which question or comment best facilitates discussion with the patient regarding his or her level of activity? A. "Do you exercise during the week?" B. "Do you keep in shape?" C. "Tell me what form of exercise you do on a daily basis?" D. "What do you do to get exercise?"

D

The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient: A. defer temperature for this age group B. oral C. rectal D. tympanic

D

The nurse is checking a patient's heart rate. An appropriate technique for an adult patient is to: A. use the pulse oximeter device to obtain heart rate. B. use the automatic blood pressure cuff to obtain heart rate. C. palpate the carotid artery for 1 full minute. D. palpate the radial artery for 15 seconds and multiply by 4 to obtain heart rate.

D

The nurse is percussing the liver of an obese patient. Which percussion finding would be expected? A. Tones with a booming quality B. An enhanced tone quality C. A higher pitch tone than in patients of a normal weight D. A reduced intensity of tone

D

The nurse is preparing to assess a patient in the hospital setting. What is the first step for the nurse? A. Don gloves B. Wear a mask C. Don goggles D. Wash hands

D

The nurse needs to assess an adolescent patient's risk for sexually transmitted diseases. What technique shows the most sensitivity? A. "Statistics show that teens between the ages of 14 and 20 are at high risk for sexually transmitted diseases. Would you more like information?" B. "What do you rate your risk of sexually transmitted disease?" C. Ask the parent, "Have you talked to your teen about sexually transmitted diseases?" D. "Many young people have questions regarding sexually transmitted diseases. What questions do you have?"

D

When assessing the quality of a patient's pain, the nurse should ask which of the following question? A. "When did the pain start?" B. "Is the pain a stabbing pain?" C. "Is it a sharp pain or dull pain?" D. "What does your pain feel like?"

D

__ is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. A. Culture B. Religion C. Spirituality D. Race

D

__ refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status. A. Discrimination B. Spirituality C. Culture sensitivity D. Diversity

D

A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission? 1. A comprehensive assessment 2. A problem-based health assessment 3. An episodic assessment 4. A screening assessment for colorectal cancer

1

A nurse is assessing a woman whose religious beliefs do not allow blood transfusions. She has severe anemia, is very weak, and has altered mental status. What should the nurse do to provide culturally competent care to this woman? 1. Examine his or her feelings about the role of religious beliefs in making decisions about life. 2. Recognize that he or she cannot provide care to patients whose religious beliefs endanger their lives. 3. Try to convince the patient to have a blood transfusion to save her own life. 4. Determine whether the patient is competent to make her own decisions about health care.

1

A patient complains of leg pain. Which question is pertinent to ask to gain additional information? 1. "What were you doing when the pain first occurred?" 2. "How do you feel about having this pain?" 3. "Do you think the pain is caused by a cramp?" 4. "Has anyone in your family ever had similar pain?"

1

Auscultation is a component of which examination technique? 1. Blood pressure measurement 2. Visual acuity 3. Examination of the ears 4. Measurement of oxygen saturation

1

During a history the patient says that she is so uncomfortable with her life that she wishes that it were over. Which is an appropriate follow-up question from the nurse? 1. "Have you thought of hurting yourself?" 2. "Oh, I've felt that way many times." 3. "That feeling will go away; just give it some time." 4. "In which ways has your life been uncomfortable?"

1

During a sports physical of a 16-year-old girl, the nurse asks which questions to collect data about drug use? 1. "Many teenagers have tried street drugs. Have you tried any?" 2. "Tell me which street drugs your friends have offered you." 3. "Do your friends tell you about the street drugs they use? 4. "Your high school has a reputation for students using street drugs. Do you use these drugs?"

1

Select the example given below that represents information a nurse collects from a patient during a physical examination. 1. Shiny skin and lack of hair found on lower legs 2. Concerned about lack of money to pay for prescriptions 3. Complains of tingling in both feet while sleeping 4. Family history of colon and breast cancer

1

The nurse records the following general inspection findings on a patient: "41-year-old Hispanic male in no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than his stated age. Patient with flat affect and makes minimal eye contact." What additional information should be added to this general inspection? 1. His body movement 2. The family history 3. The estimated size of his liver 4. His pulse rate

1

Which communication technique conveys genuine interest in what the patient has to say? 1. Active listening 2. Sitting close to the patient 3. Maintaining professional dress and conduct 4. Holding the patient's hand during the interview

1

While examining a patient with an infected abdominal incision, the nurse notices that it is very malodorous. Which technique does this represent? 1. Inspection 2. Palpation 3. Auscultation 4. Percussion

1

A female has been admitted to the emergency department with severe abdominal pain. She is lying on a stretcher quietly, with very little movement. Which patient response should the nurse anticipate when palpating this patient's abdomen? 1. Flushing of the face and neck 2. Guarding over the abdomen 3. Redness on the lower abdominal quadrants 4. Decreased peristalsis

2

A nurse is teaching a family from Guatemala about the importance of exercise to reduce body weight. The husband asks, "What exercise should we do?" Considering the time orientation of this family, what is the most effective way for the nurse to respond? 1. "Research has shown that walking 30 minutes most days of the week is best." 2. "Is there an exercise that you can do today for 30 minutes and add it to your daily routine?" 3. "If you exercise 30 minutes most days of the week, you can lose weight by your next visit." 4. "I have always found that resistance weight training each day for 30 minutes is effective."

2

A patient had a knee replaced because of arthritis. He reports that he has not slept well for several nights. He states that he can't get comfortable. Today he is asking for pain medication more often. What could be a reason for this increase in pain? 1. Arthritis pain is variable; it can be mild one day and severe the next. 2. Pain tolerance decreases with sleep deprivation. 3. The anesthesia from surgery is wearing off. 4. The patient is using the pain medication to help him sleep during the day.

2

A school nurse notices a boy with a bandage on his arm and black fluid under the edge of the bandage. She asks the teen what happened to his arm. He replies that his mother applied axle grease to a boil. What is the nurse's most appropriate response to this boy? 1. Tell the teen to remove the bandage and wash his arm. 2. Ask the teen what the boil looks like and feels like and if the axle grease is healing the boil. 3. Advise the teen to tell his mother to use antibiotic cream rather than axle grease. 4. Suggest that the teen see a health care provider because the axle grease will infect the boil.

2

After collecting data, the nurse begins data analysis with which activity? 1. Documenting information from the history 2. Organizing the data collected 3. Reporting data to other care providers 4. Recording data from the physical examination

2

The nurse is caring for a patient with a femur fracture. An immobilization device is used to maintain the alignment of the femur. The nurse palpates the top of the foot to make which determination? 1. Amount of drainage from the wound 2. Adequacy of blood perfusion to the foot 3. Presence of air in the underlying tissue 4. Range of motion to the foot

2

The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? 1. "How often do you visit the medicine man for your health care?" 2. "Tell me about your health care beliefs and practices." 3. "Many Navajo people are afraid of hospitals. Are you afraid?" 4. "Have you ever had a physical examination with a physician or a nurse practitioner?"

2

The nurse obtains vital signs on a 42-year-old man having his annual physical examination. He has no medical conditions and states that his health is excellent. Using an automated blood pressure device, his blood pressure is measured as 62/40. Which action by the nurse is most appropriate? 1. Obtain a different cuff and take the blood pressure again. 2. Take the blood pressure again using the auscultation method. 3. Place the patient in a supine position and take the pressure on the leg. 4. Record the blood pressure and continue with the examination.

2

Which question is appropriate for a nurse to ask at the beginning of a mental health history? 1. "Have you been feeling anxious or sad?" 2. "How have you been feeling about yourself?" 3. "Are you alone a lot, or do you socialize with friends?" 4. "How are you dealing with the stressors in your life?"

2

Which situation illustrates a screening assessment? 1. A patient visits a clinic for the first time and the nurse completes a history and physical examination. 2. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels. 3. A nurse at an urgent care center checks the blood pressure, pulse, temperature, and respirations of a patient reporting leg pain. 4. A patient with diabetes mellitus comes to the laboratory to get her blood glucose tested prior to a visit with a health care provider.

2

Which technique does a nurse use to assess the mental status of patients? 1. Ask them about any of their relatives who have mental health disorders. 2. Have them calculate the change to expect after making a purchase. 3. Ask them to recall how they cope with stress on a daily basis. 4. Have them describe the moods and emotions they experience on a usual day.

2

A nurse is caring for a woman who has just been pronounced dead. Her adult children are in the room. Which statement by the nurse indicates culturally competent care? 1. "Which funeral home would you like notified of your mother's death?" 2. "We will be moving her to the morgue in about 30 minutes." 3. "Would you like some time alone with your mother for any specific ceremonies?" 4. "Here are some of her personal belongings that were in the drawer."

3

A patient complains of chest pain. Which question has the highest priority to obtain additional information? 1. "What were you doing when the pain first occurred?" 2. "Do you have shortness of breath with the chest pain?" 3. "What does the pain feel like?" 4. "Has anyone in your family ever had similar pain?"

3

A patient is brought to the emergency department in severe respiratory distress. Which method of temperature measurement would be the most appropriate? 1. Oral temperature 2. Axillary temperature 3. Temporal artery 4. Rectal temperature

3

An older man who is near death has been admitted to the hospital, and his family members are at his bedside. Which question or statement should the nurse use during the admission assessment to address the spiritual needs of the patient and his family appropriately? 1. "What is your religion? I'll make the appropriate spiritual arrangements." 2. "Tell me what death means to people from your culture." 3. "Are there any special needs that you and your family request at this time?" 4. "I'll call the hospital priest so he can administer last rites."

3

During a health history a patient says, "Stressors? Oh, yeah, I have stressors. I got a promotion at work; and, with the extra income I'm going to move into a new house, but that has been delayed because my mother is in the hospital and my son is going off to college. To get through this time I just keep using my support systems, exercising, and meditating." How does a nurse interpret these comments by this patient? 1. Flight of ideas 2. Moderate anxiety 3. Positive coping strategies 4. Rationalization and denial

3

During an interview, an elderly patient tells the nurse that she has periodic problems in keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom analysis is the nurse pursuing with this question? 1. Severity 2. Frequency 3. Aggravating factors 4. Location

3

The nurse documents which information in the patient's history? 1. The patient is scratching his left arm. 2. The patient's skin feels warm. 3. The patient reports itching of her eyes. 4. The patient's temperature is 100°F.

3

Which assessment data are determined by the use of a goniometer? 1. Auscultation of fetal heart tones 2. Inspection of the cervix 3. Measurement of joint flexion 4. Assessment of hearing

3

Which set of vital signs should the nurse recognize as out of the expected range? 1. 42-year-old man: BP, 114/82; pulse, 74 beats/min; respiration, 16 breaths/min; temperature, 36.8° C 2. 11-year-old girl: pulse, 88 beats/min; respiration, 22 breaths/min; temperature, 36.7° C 3. 3-year-old boy: pulse, 130 beats/min; respiration, 44 breaths/min; temperature, 36.7° C 4. 1-month-old girl: pulse, 120 beats/min; respiration, 42 breaths/min; temperature, 36.7° C

3

A 62-year-old patient tells the nurse that he has recently had frequent fainting spells. After palpating the radial pulse, 13 pulsations are counted in 15 seconds with a regularly irregular rhythm. What is the most appropriate action for the nurse to take at this time? 1. Reassess the pulse rate after he walks around the room for several minutes. 2. Reassess the pulse rate for 15 seconds using the carotid artery. 3. Take an apical pulse for 5 full minutes, counting the number of skipped beats. 4. Palpate the pulse for one l minute and determine the pattern to the irregularity.

4

A 62-year-old patient tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patient's statement? 1. "Do you avoid taking drugs because of bad experiences?" 2. "Which medications have you taken in the past?" 3. "That is hard to believe. Most men your age take medications." 4. "Do you use over-the-counter medications or herbal preparations?"

4

A patient reports nausea and vomiting; and the nurse observes hand tremors, agitation, and sweating. In view of these findings, which additional data would the nurse need to collect? 1. Which fears or stressors the patient has been experiencing 2. When the patient last took illegal drugs and which one was taken 3. Which kinds of obsessions or compulsions the patient has been experiencing 4. When the patient last drank alcohol and how much was consumed

4

The nurse is conducting an interview with Jeremy, a 17-year-old accompanied by his mother. Which statement made by the nurse is an age-appropriate adjustment when conducting a health history with an adolescent? 1. "Jeremy, do you have a girlfriend, and if so are you sexually active yet?" 2. "Mrs. Williams, is your son sexually active yet?" 3. "Jeremy, how do you incorporate safe sex practices into your daily life?" 4. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy?"

4

What is the most reliable way to assess pain in a patient who is cognitively intact? 1. Type and frequency of analgesic medications the patient takes 2. Patient's most recent vital signs (e.g., blood pressure and pulse rate) 3. Extent of tissue damage the patient has experienced 4. Report by the patient describing the pain experienced

4

Which infection control intervention is most frequently applied? 1. Wearing gloves 2. Using masks 3. Wearing eye protection 4. Hand hygiene

4

A patient tells the nurse that he has had a headache and nausea for 3 days. Which type of assessment should the nurse perform? A. Focused assessment B. Episodic follow-up assessment C. Shift assessment D. Comprehensive health assessment

A

In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the __. A. history of present illness B. biographic data C. present health status D. review of symptoms

A

The nurse is administering an influenza (flu) shot to a patient in a retail health setting. Of which level of prevention is this an example? A. Primary B. Secondary C. Post-secondary D. Tertiary

A

The nurse is assessing a patient who has pain with a sudden onset and a limited duration and that subsides as healing occurs. Which type of pain would this be considered? A. Acute pain B. Chronic pain C. Cancer pain D. Nonmalignant pain

A

The nurse is assessing a superficial mass on a patient skin surface. Which part of the hand is used to palpate a superficial mass in the skin? A. The fingertips B. The heel of the hand C. The dorsal surface of the hand D. The ulnar surface of the hand

A

The nurse is conducting an interview. During an interview, the primary type of data being collected is: A. subjective data. B. objective data. C. secondary data. D. recent data.

A

The nurse is documenting the findings from the health assessment. Which example of data documentation reflects the opinion of the nurse? A. The patient is uncooperative and unfriendly. B. The patient avoids eye contact. C. The patient states, "I do not want to get out of bed." D. The patient states, "I am very angry."

A

The nurse is interviewing a patient for the first time. The nurse can expect the interview to be conducted in which type of order? A. Introduction, discussion, and summary B. Assessment, planning, intervention, and evaluation C. Discussion, introduction, and summary D. Assessment, evaluation, planning, and reevaluation

A

The nurse is obtaining a patient's blood pressure and suspects that the reading is a false-high reading. What leads the nurse to confirm this suspicion? A. Using a cuff that is too narrow B. Having the examiner's eyes looking down at the meniscus C. Deflating the cuff too rapidly D. Positioning patient's arm below the level of the heart

A

The nurse is performing a cultural assessment for an immigrant from Mexico. The patient is having difficulty adapting to the American health system. What is the most likely explanation for this problem? A. Culture shock B. Cultural taboos C. Cultural unfamiliarity D. Culture disorientation

A

The nurse notices that a patient has difficulty separating relevant from irrelevant information during a conversation. This patient is having difficulty with: A. circumstantiality. B. neologism. C. blocking. D. flight of ideas.

A

The nurse suspects that a patient has a fungal infection of the skin. Which instrument helps confirm this suspicion? A. Wood's lamp B. Otoscope C. Sniff test D. Slit lamp

A

__ pain is associated with feeling pain when a limb has been amputated. A. Phantom B. Psychotic C. Chronic D. Invisible

A

The nurse is obtaining the mental health history of a new patient. What should the nurse include in the mental health history? Select all that apply. A. The patient's description of self B. A past medical history C. The current medications the patient is taking D. Cultural beliefs E. Spiritual beliefs

A, B, C

The nurse is assessing a patient's spiritual beliefs and practices. Which questions should be considered part of the assessment? Select all that apply. A. What type of spiritual/religious support do you desire? B. What is the name of your clergy, ministers, chaplains, pastor, rabbi? C. What does pain mean to you? D. What does dying mean to you? E. What are your educational goals? F. Do you use prayer in your life?

A, B, D, F

The student nurse is preparing to assess a patient in the hospital clinical setting. Which components best describe the concept of health assessment? Select all that apply. A. Collection of objective data B. Collection of subjective data C. Collection of data and identification of nursing diagnosis D. Planning and evaluation of data E. Analysis of data F. Physical exam G. Documentation of data

A, B, E, F

Which are considered basic techniques for physical assessment? Select all that apply. A. Palpation B. Medication reconciliation C. Inspection D. Auscultation E. History of present illness F. Percussion

A, C, D, F

Examples of providing culturally competent care are: Select all that apply. A. understands people from cultures other than his or her own. B. speaks at least one foreign language. C. seeks knowledge of the health beliefs and practice of all the cultures. D. has visited a foreign country. E. incorporates foods from home into the diet. F. allows for complementary interventions for pain relief.

A, C, E, F

The nurse is compelled to address and manage a patient's pain level by which ethical principles? Select all that apply. A. Beneficence B. Liberty C. Autonomy D. Nonmaleficence E. Justice

A, D

The nurse is incorporating the principles of the quality and safety competencies from the Institute of Medicine (IOM) recommendations into the health assessment of a patient in the long-term care setting. What principles should the nurse consider? Select all that apply. A. Use evidence to support interventions. B. Evaluate the plan of care. C. Use a step-by-step approach to problem solving. D. Use technologies and informatics in delivering care. E. Place the patient at the center of care. F. Include other disciplines in the plan of care.

A, D, E, F

The nurse is conducting a data analysis on objective information obtained during the health history. What should be included? Select all that apply. A. Vital signs B. Pain assessment C. Review of symptoms D. Surgical history E. Social history F. Heart murmur

A, F

An adult patient is being assessed in the outpatient clinic secondary to a recent weight loss. Why is the weight of an adult patient measured routinely during a physical assessment? A. It allows assessment of body fat content. B. A change in body weight can be indicative of health problems. C. Fat deposits in specific locations can be identified. D. It identifies patients who exercise and those who do not exercise.

B

An elderly African-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse should: A. perform a physical examination. B. recognize and accept different beliefs about health. C. identify high-risk patients for various diseases. D. apply statistical trends of various ethnic and cultural groups.

B

The nurse is assessing a patient who does not speak English. When checking the visual acuity of a non-English-speaking patient, the nurse should use which chart? A. Snellen chart B. Snellen E chart C. Rosenbaum pocket screener D. Pupil gauge chart

B

The nurse is assessing the degree of pain or discomfort a patient is feeling. The nurse knows that this will be dependent primarily on: A. ability to explain the pain or discomfort. B. perception of the pain or discomfort. C. age of the individual. D. type of painful stimulus.

B

The nurse is auscultating the lungs to listen for breath sounds. What sounds will indicate that the nurse is auscultating correctly? A. The nurse will hear the diffusion of air and carbon dioxide. B. The nurse will hear the air move in and out of the lungs. C. The nurse will hear a lub/dub sound. D. The nurse will hear gurgling noises.

B

The nurse is caring for a patient in the mental health facility who has a diagnosis of bipolar disorder. The nurse knows that this is because mental health is directly affected by the: A. cerebral spinal fluid. B. neurotransmitters. C. thickness of the dura mater. D. the pia mater.

B

The nurse is conducting an interview with a patient who is mentally challenged. The nurse knows that __ assessment is the preferred method for this interview. A. comprehensive B. focused C. family D. health risk

B

The nurse is counting an infant's respirations. Which technique is correct? A. Watch the chest rise and fall. B. Watch the abdomen for movement. C. Place a hand across the infant's chest. D. Use a stethoscope to listen to the breath sounds.

B

The nurse is focusing the interview for a patient who complains of headaches and nausea. Which interview format is based on body function as opposed to body system? A. Review of systems B. Functional health patterns C. Health perception database D. Nursing process

B

The nurse is reviewing concepts related to one's heritage and beliefs. The belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: A. culture. B. religion. C. ethnicity. D. spirituality.

B

The nurse is reviewing the pathophysiology of pain. Where does the perception of pain actually occur? A. The dorsal horn of the spinal cord B. The parietal lobe of the cerebral cortex C. The afferent (sensory) nerves D. The visceral and somatic free nerve endings (nociceptors)

B

The nurse is taking a patient's oral temperature. How should the nurse perform the procedure? The thermometer should be placed: A. under the tongue next to the frenulum of the lower lip. B. under the tongue in the posterior sublingual pocket. C. between the tongue and the hard palate. D. along the outer aspect of the lower molars and against the cheek.

B

The nurse should use a(n) __to auscultate the chest and abdomen. A. Doppler B. stethoscope C. audiometer D. transilluminator

B

The nurse is assessing for objective findings are associated with the patient's pain level. Which findings are commonly associated with acute pain? Select all that apply. A. The patient is crying B. An elevated blood pressure C. An elevated heart rate D. Diaphoresis E. The patient states a pain level of 8 out of 10 on pain scale F. Vital signs stable

B, C, D

The nurse knows that the single most important factor in conducting an interview is the communication process. Which factors will most likely affect a positive interview process and therapeutic communication? Select all that apply. A. Obtaining the patient's history B. Maintaining privacy C. Asking open-ended questions D. Conducting a fast, efficient interview E. Obtaining answer to questions in advance F. Asking closed-ended questions G. Asking how the patient is feeling today

B, C, G

The student nurse is learning how to obtain blood pressures and is studying what factors can affect blood pressure. What should the student nurse include as factors that affect blood pressure? Select all that apply. A. What the person ate B. Smoking C. Mobility D. Race E. Gender F. Weight G. Pain

B, D, E, F, G

Pulse oximetry is used to: Select all that apply. A. detect pulsation in the veins. B. estimate the oxygen saturation of arterial blood. C. determine hemoglobin D. percentages of the blood. E. estimate the saturation of oxygen in the alveoli. F. assess heart rate.

B, E

A patient complains of a cough for 4 days unrelieved with position changes. The nurse interprets this as a symptom and documents the finding under __on the patient's chart. A. the nursing care plan B. assessment C. history D. vital signs

C

After the nurse has completed the interview, a symptom analysis is performed to derive appropriate interventions. What is the best description of symptom analysis? A. A way to document a comprehensive interview B. A method of collecting data about a patient's past medical history C. A systematic collection of subjective data related to the patient's chief complaint D. Interview data collected through the use of an interpreter

C

The nurse is obtaining a pulse oximeter reading on an adult patient. Where is the probe of a pulse oximeter placed? A. In the mouth or under the arm B. On the ear C. On the tip of a finger or toe or on an ear lobe D. In the rectum

C

The nurse is palpating the abdomen of a patient. How deep should the hands press while performing deep palpation? A. 1 cm B. 2 cm C. 4 cm D. 8 cm

C

The nurse is percussing a patient's abdomen. What sound will the nurse most likely percuss? A. Resonance B. Dullness C. Tympany D. Flatness

C

The nurse is performing a pain assessment of a 4-year-old toddler. Which pain assessment scale would be best for this patient? A. Visual Analog Scale B. Numeric Pain Intensity Scale C. Wong/Baker Faces Rating Scale D. Pain Intensity Scale

C

The nurse is planning to teach a group of patients stress reduction exercises to reduce the risk of depression. Which population group is at highest risk for depression? A. Males B. School-age children C. Adolescents D. Individuals starting new careers

C

The nurse knows that the __ blood vessels should be used to assess an adult's blood pressure. A. carotid artery B. brachial vein C. brachial artery D. radial artery

C

The nurse states, "All homosexuals have HIV infection." This statement is an example of: A. sexism B. prejudice C. stereotyping D. racism

C

What standards or guidelines exist to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the United States? A. Each ethnic group has its own written standards for competent cultural care. B. There are no standards or guidelines for giving competent cultural care. C. The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. D. The American Society of Cultural Competence has guidelines containing the health beliefs and practices of major cultural groups.

C

Which findings by the nurse would produce the most accurate assessment of the severity level of a patient's pain? A. The nurse's experience B. The cause of the pain C. The patient's subjective data D. The patient's objective findings

C

Which is a common mistake made by health care professionals when collecting data about ethnic and cultural considerations of a patient? A. Acknowledging the practice of folk or herbal remedies B. Adapting health care concepts to meet the needs of individuals of other cultures C. Assuming data about the patient based on skin color or ethnic group D. Overestimating the ability of individuals from diverse cultures to understand health care concepts

C

The nurse is attending an in-service on pain management for postoperative patients. Which statement regarding pain is true? Select all that apply. A. An individual's pain response is predictable based on his or her culture or ethnicity. B. Individuals from all cultures respond to pain similarly. C. The pain response may be influenced by one's culture. D. Individuals may express pain differently. E. Pain management may vary depending on the source of pain.

C, D, E,