Health Assessment - Exam 1

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. "Many young people have questions regarding sexually transmitted diseases. What questions do you have?" When asking questions about sensitive issues, the nurse explains that there are personal or sensitive questions to ask. Another technique is referred to as permission giving. For example, the nurse might say, "Many people have experimented with drugs; have you ever used street drugs?" or "Many young people your age have questions about sex. What questions or concerns do you have?" With the permission-giving technique, the nurse communicates to the patient that it is safe to discuss such topics.

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?" 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. "What do you do to get exercise?" This question allows for discussion of the patient's activity level.

When assessing the quality of a patient's pain, the nurse should ask which 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. "What does your pain feel like?" To assess the quality of a person's pain, have the patient describe the pain in his or her own words.

According to the food plan, what represents one serving from the bread, cereal, and grain products group? A. 1 cup cooked rice B. 6 soda crackers C. 1 hamburger bun D. 1 slice of bread

D. 1 slice of bread D. One slice of bread represents one serving from this group. A. One-half cup cooked rice represents one serving from this group. B. Three to four crackers represent one serving from this group. C. One hamburger bun represents two servings from this group.

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. A reduced intensity of tone The thickness of tissue can impair vibrations, causing quieter percussion tones

An insufficient amount of the neurotransmitter GABA may result in _________________. A. Depression B. Hallucinations C. Delusions D. Anxiety

D. Anxiety GABA suppresses neurotransmission, which helps to control anxiety.

The nurse is assessing a patient's dietary intake to help the patient lose weight. What is the easiest way to assess the patient's normal dietary intake? A. Comparing established eating habits with Dietary Reference Intakes B. Asking the nurse to fill out a food plan C. Comparing the recommended dietary allowances to the USDA MyPlate D. Asking the patient to do a 24-hour dietary recall

D. Asking the patient to do a 24-hour dietary recall Having the patient do a 24-hour food recall will assist the nurse in collaborating with the patient to include foods that the patient enjoys. This will likely lead to adherence to the plan for two reasons: 1. The patient is involved in the plan. 2. The patient will not be deprived of favorite foods.

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. Assessment, diagnosis, outcome identification, planning, implementation, evaluation The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nurse must analyze and interpret these data before initiating a plan of care.

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. Comprehensive health assessment The type of health assessment performed by the nurse is also driven by patient need. A comprehensive health assessment involves a detailed history and physical examination performed at the onset of care in a primary care setting or upon admission to a hospital or long-term care facility.

__________ 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. Diversity Diversity refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status.

Which process does the clustering of data facilitate? A. Analyzing data B. Collecting data C. Implementing nursing care D. Evaluating nursing care

D. Evaluating nursing care

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

D. Flatness Flatness is heard over bones and muscle. Detecting sound changes is easier when moving from resonance to dullness (e.g., from the lung to the liver).

The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected finding? A. Newborns B. Young children C. Adolescents D. Older adults

D. Older adults These lesions are fairly common in older adults.

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. Palpate the radial artery for 15 seconds and multiply by 4 to obtain heart rate. For adults, the radial artery is used generally for heart rate.

The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: A. Auscultating the skin to note the presence of motility sounds B. Pressing on the skin and observing the depression C. Stretching the skin and observing for a degree of flexibility D. Pinching the skin and watching the skin return to place

D. Pinching the skin and watching the skin return to place The skin under the clavicle is frequently used.

_________ 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. Race Race is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color.

The nurse suspects that the patient is suffering from malnutrition. Which laboratory test indicates a patient's protein calorie status? A. Hemoglobin and hematocrit B. Serum glucose levels C. Lipid profile D. Serum albumin

D. Serum albumin Serum albumin measures serum protein.

The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? A. The width of the nail base B. The color of the nail C. The thickness of the nail D. The angle of the nail base

D. The angle of the nail base Clubbing is associated with an increased nail bed angle.

The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient's: A. Defer temperature for this age group B. Oral C. Rectal D. Tympanic

D. Tympanic Tympanic is preferred secondary to activity level of toddler and efficiency of method.

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

D. Wash hands Hand hygiene is considered to be the single most important action to reduce transmission of infection and is considered an essential element of standard precautions.

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, psychological, 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. context of care

During an interview an elderly patient tells the nurse that she has periodic problems 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? A. Severity B. Frequency C Aggravating factors D. Location

3. Aggravating factors

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, F, G Collection of objective data Collection of subjective data Physical exam Documentation of Data Components of health assessment include conducting a health history (the collection of subjective data), performing a physical examination (the collection of objective data), and documenting the findings.

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 Use Evidence to support interventions Use technologies and informatics in delivering care Place the patient at the center of care Include other disciplines in care The Institute of Medicine identified five core competencies as essential for health care professionals to demonstrate how to respond effectively to patient care needs: provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics.

The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the nurse recommend for this patient? A. 2 to 3 B. 3 to 5 C. 5 to 6 D. 0 to 2

A. 2 to 3 Between 2 and 3 servings is the recommended daily intake of dairy.

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? A. A comprehensive assessment B. A problem-based health assessment C. An episodic assessment D. A screening assessment for colorectal cancer

A. A comprehensive assessment

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. Acute pain By definition, acute pain is pain that lasts less than 6 months.

The school nurse is assessing the nutritional status of a healthy adolescent. Which assessment will the nurse include in this assessment? Select all that apply: A. Anthropometrics B. Biochemical tests results C. Clinical evaluation of diet D. Dietary assessment E. Body Mass Index (BMI)

A. Anthropometrics C. Clinical evaluation of diet D. Dietary assessment E. Body Mass Index (BMI)

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

A. Beneficence D. Nonmaleficence The ethical principles of beneficence (the duty to benefit another) and nonmaleficence (the duty to do no harm) compel health care professionals to provide pain management and comfort.

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. Circumstantiality This may not always be immediately apparent.

The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What would the nurse include as the most common cause of skin lesions for this age group? A. Communicable disease and bacterial infection B. Changes in skin turgor and skin tone C. Maturation of melanocytes, causing changes in skin color D. Skin inflammation from sebaceous gland activity

A. Communicable disease and bacterial infection These spread quickly among those in this age group.

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. Culture shock 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 nurse suspects altered thought processes. Which findings might suggest an altered thought process? Select all that apply: A. Dress or appearance B. Socioeconomic issues C. Cultural differences D. Problems articulating words E. Tone of voice

A. Dress or appearance D. Problems articulating words E. Tone of voice Socioeconomic issues and cultural differences do not affect mental status.

The nurse is performing a mental health assessment. Data collection for mental health assessment begins when the nurse: A. First sees the patient B. Obtains biographic data C. Begins the history D. Ends the examination

A. First sees the patient The patient's appearance, dress, and body posture are all important data to include in the mental health assessment.

The nurse is teaching a patient the importance of protein for healing. Which foods should the nurse include in the teaching plan? A. Fish B. Cereal C. Bread D. Oatmeal

A. Fish Fish contains all of the essential amino acids.

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

A. Introduction, discussion, summary The interview consists of three phases: introduction, discussion, and summary. To begin the introduction phase, nurses introduce themselves and inform patients about their role in the patient's care. Assessment includes gathering subjective and objective data.

The nurse is performing a skin assessment and finds that the patient has milia. In which age group would this be an expected finding? A. Newborns B. Young children C. Adolescents D. Older adults

A. Newborns Milia are small white papules found on the face of a newborn infant.

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. Palpation C. Inspection D. Auscultation F. Percussion Data for physical assessment are collected using four basic assessment techniques: inspection, palpation, percussion, and auscultation

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

A. Phantom pain This occurs most often in individuals who experienced pain in the appendage or limb before the amputation.

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. Primary Prevention Vaccinations protect from disease and are considered primary prevention.

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

A. Resonance Resonance is heard over healthy lung tissue, whereas hyperresonance is heard in overinflated lungs (as in emphysema).

The nurse knows that the functions of the skin include: Select all that apply: A. Sensory input B. Protection C. Production of vitamin D D. Temperature regulation E. Production of vitamin C F. Sensory output

A. Sensory input B. Protection C. Production of vitamin D D. Temperature regulation the skin does not produce vitamin C or play a role in sensory output.

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. Subjective Data Subjective data is what the patient tells you.

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 patient is uncooperative and unfriendly Nurses must record data accurately, concisely, and without bias or opinion. In this example, the nurse is offering an opinion, which may contain bias.

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 patients description of self B. A past medical history C. The current medications the patient is taking D. Cultural beliefs E. Spiritual beliefs

A. The patients description of self B. A past medical history C. The current medications the patient is taking Cultural and spiritual beliefs are part of the social history and are incorporated into the plan of care but not included into the mental health history.

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. Understands people from cultures other than his or her own C. Seeks knowledge of the health beliefs and practice of all the cultures E. Incorporates foods from home into the diet F. Allows for complementary interventions for pain relief Gaining an understanding of each patients culture is the basis for competent care, allowing for complementary modalities. Seeking knowledge and incorporating special food are examples of cultural competent care.

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. Using a cuff that is too narrow A narrow cuff can result in a false-high reading.

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. Vital signs F. Heart murmur Pain assessment, review of symptoms, surgical history, and social history are considered subjective data.

The nurse is assessing a patients 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. What type of spiritual/religious support do you desire? B. What is the name of your clergy, ministers, chaplains, pastor, rabbi? D. What does dying mean to you? F. Do you use prayer in your life? These are all questions related to spiritual assessment.

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. focused assessment The type of health assessment performed by the nurse is also driven by patient need. A focused assessment involves a history and examination that are limited to a specific problem or complaint.

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 fingertips The fingertips are the most sensitive part of the hand and are used for superficial palpation.

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. woods lamp A Wood's lamp is used to detect fungal infections of the skin. Lesions of the skin appear as a fluorescent yellow-green or blue-green color.

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 patients 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 Maintaining privacy Asking open ended questions Asking how the patient is feeling today Numerous factors affect the interview and the communication process, including the physical setting, nurses behaviors, the type of questions asked and how they are asked. In addition, the personality and behavior of patients, how they are feeling at the time of the interview, and the nature of information being discussed or problem being confronted may affect the data revealed.

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. A change in body weight can be indicative of health problems. This is especially true with a sudden, excessive weight gain or loss.

In which age group is skipping meals most commonly seen? A. School-age children B. Adolescents C. Adults D. Older adults

B. Adolescents Eating patterns may reveal poor eating habits associated with multiple school or athletic activities.

The nurse is assessing for objective findings are associated with the patients 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. An elevated blood pressure C. An elevated heart rate D. Diaphoresis Crying and pain level are subjective findings. Vital signs will most likely be elevated during acute pain.

The nurse is assessing an elderly patient's risk of nutritional deficiency. An important risk factor for nutritional deficiency in the elderly is: A. Increased blood pressure B. Decreased activities of daily living C. An allergy to shellfish D. Exercise pattern

B. Decreased activities of daily living It is important to determine if the patient is capable of obtaining and preparing adequate food.

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

B. Dullness Dullness is heard over the liver.

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 percentages of the blood. D. Estimate the saturation of oxygen in the alveoli. E. Assess heart rate

B. Estimate the oxygen saturation of the arterial blood E. Assess the heart rate A pulse oximeter estimates the oxygen saturation of arterial blood and pulse or heart rate

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. Focused Conducting an interview with a patient in physical or emotional distress is difficult. In such case, use a focused assessment to limit the number and nature of questions to those absolutely necessary for the given situation, and save additional questions for a later time.

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. Functional health patterns Review of systems is very different from the body function format.

The nurse is assessing the patient's stressors. Which tool can be used to identify the degree of stressors a patient may be experiencing? A. CAGE B. Holmes Social Readjustment Inventory Scale C. AUDIT D. Mini-Mental State

B. Holmes Social Readjustment Inventory Scale This tool may help to identify a high-risk individual.

The nurse is assessing a patient who recently was diagnosed with a stroke. The patient is very emotional. In what part of the brain did the stroke most likely occur? A. Brainstem B. Limbic system C. Prefrontal lobe D. Cerebellum

B. Limbic system Regulation of memory and basic emotion such as fear, anger, and sex drive are regulated by the limbic system, also called the emotional brain.

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. Neurotransmitters The neurotransmitters involved include norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA).

The nurse is assessing the degree of pain or discomfort a patient is feeling. The nurse knows that this will be dependent primarily on the: 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. Perception of the pain or discomfort Individuals may perceive a stimulus differently, making the pain experience very individualized.

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. Recognize and accept different beliefs about health The nurse should recognize the difference in beliefs. Although the nurse does not have to agree with another's beliefs, he or she must be accepting of those important to the patient.

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. Religion 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.

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. Snellen E chart The patient can indicate which direction the legs are on the E point

The nurse should use a(n) _________to auscultate the chest and abdomen. A. Doppler B. Stethoscope C. Audiometer D. Transilluminator

B. Stethoscope A stethoscope assists in the identification of internal sounds.

The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers that react to touch, pain, and temperature? A. The epidermis B. The dermis C. The hypodermic D. The subcutaneous tissue

B. The dermis The dermis contains the nerves and vascular supply.

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 will hear the air move in and out of the lungs. If the stethoscope is placed over the lung fields, the nurse should hear air moving in and out of the lungs.

A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve? A. The tympanic membrane B. The ossicle C. The organ of Corti D. The tragus

B. The ossicle Three tiny bones make up the ossicle. This structure transmits sound.

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 parietal lobe of the cerebral cortex Pain is not actually perceived until the parietal lobe is stimulated.

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 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. Under the tongue in the posterior sublingual pocket Placing the thermometer under the tongue in the posterior sublingual pocket provides the most accurate temperature.

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. Watch the abdomen for movement. Watch the infant's abdomen for movement because the infant's respirations are normally more diaphragmatic than thoracic.

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. smoking D. Race E. Gender F. Weight G. Pain B. Ingesting caffeine or smoking a cigarette within 30 minutes before measurement may increase blood pressure D. The incidence of hypertension is twice as high in African Americans as in whites. E. After puberty, females usually have a lower blood pressure than males; however, after menopause, womens blood pressure may be higher than mens F. Obese patients tend to have higher blood pressures than nonobese patients. G. Experiencing acute pain can increase blood pressure.

A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the nurse what could be causing this? The nurse's best response is: A. "Macules need to be watched closely for signs of skin cancer." B. "Macules are warts and should be removed." C. "Macules are freckles are considered normal on the skin." C. "You have an infection and will need an antibiotic."

C. "Macules are freckles are considered normal on the skin." Another name for macules is freckles. Freckles are considered normal and benign.

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. 4 cm Deep palpation is done with one or two hands to a depth of 1.6 inches or 4 cm

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. A systematic collection of subjective data related to the patient's chief complaint This process can be used with any complaint a patient may have.

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. Adolescents Peer pressure and independence contribute to their increased risk.

The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n): A. Yellowish-green skin B. Deeper tone of brown or purple C. Ashen gray color to the skin D. Cluster of dark spots over the skin surface

C. Ashen gray color to the skin This is easiest to see in the oral mucous membranes, nail beds, and conjunctiva of the eye.

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. Assuming data about the patient based on skin color or ethnic group This is very easy to do but also can impair therapeutic relationships between the patient and nurse. It also interferes with providing care based on the patient's needs.

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. Brachial artery The brachial artery is found near the antecubital space.

The formation of a plan of care is initiated with: A. Analysis of data B. Collection of data C. Clustering of data D. Identification of nursing diagnoses

C. Clustering of data

The nurse is aware that the greatest physical variation of ears among individuals of different races is: A. The size of the ear B. Hearing acuity C. Consistency and color of cerumen D. The length of the auditory canal

C. Consistency and color of cerumen Asian and American Indian and Alaska natives have sparse, dry, flaky cerumen, whereas white and dark-skinned races have moist, sticky, and dark cerumen.

During an interview the nurse learns that a patient has a 5-year history of hypertension. Which health promotion intervention is most appropriate at this time? A. Teaching the patient how to relieve stress to prevent hypertension B. Monitoring and minimizing the progression of hypertension C. Establishing a screening schedule for detection of hypertension D. Advising the patient on the benefits of exercise to lower blood pressure

C. Establishing a screening schedule for detection of hypertension

The nurse is assessing a patient's nutritional status and suspects the patient needs more macronutrients. Which are considered macronutrients? A. Minerals B. Vitamins C. Fats D. Water

C. Fats Macronutrients include carbohydrates, proteins, and fats.

The nurse is working with a patient to develop a nutritional plan for a patient newly diagnosed with diabetes. The nurse assesses what the patient's food preferences are because: A. Food preferences can indicate a chronic disease that the nurse may be unaware of B. Life expectancy can be predicted based on food preferences C. Food preferences and dislikes have a strong influence on what a person eats D. A list of food preferences will help identify individuals who will not comply with special diets

C. Food preferences and dislikes have a strong influence on what a person eats This becomes important with dietary teaching.

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. History A symptom is something described by the patient and considered subjective; therefore it would be documented under "History."

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

C. History of present illness This may be a problem or a routine health care issue.

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. On the tip of a finger or toe or on an ear lobe It is important to know how to attach the probe.

The nurse is using the CAGE screening tool. This tool is used to screen for what? A. Sexual activity B. Depression C. Problem alcohol use D. Decreased mental status

C. Problem alcohol use CAGE is one of the most popular screening tools used to assess alcohol use.

The nurse states, "All homosexuals have HIV infection." This statement is an example of: A. Sexism B. Prejudice C. Stereotyping D. Racism

C. Stereotyping Although some homosexuals have HIV infection, not all do. This is a stereotypical statement.

A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What type of data does this information represent? A. Subjective data B. Objective data C. Subjective and objective data D. Secondary source data

C. Subjective and objective data

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 of America? 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. The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. There are 14 standards that provide for culturally and linguistically appropriate services (CLAS).

A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further investigate a lesion? A. The lesion is dark brown. B. The lesion has been present for 20 years. C. The lesion bleeds easily when it is touched. D. The lesion is slightly raised and circumscribed.

C. The lesion bleeds easily when it is touched. A lesion that bleeds easily could be malignant.

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 individuals 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 ones culture. D. Individuals may express pain differently. E. Pain management may vary depending on the source of pain.

C. The pain response may be influenced by ones culture. D. Individuals may express pain differently. E. Pain management may vary depending on the source of pain. Culture influences how an individual responds to pain. Pain tolerance is highly variable. Patients may need narcotics for postoperative pain, whereas muscle strains may respond well to anti-inflammatory medications.

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. The patient's subjective data The most accurate and reliable evidence of pain is the patient's report.

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. Tympany Tympany is normally heard over the abdomen

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. Wong/Baker Faces Rating Scale This scale is works well for children over 3 years of age because it has pictures.