HealthAssessmentExam1

A 25 year old male patient has a heart rate of 60, and it has been this rate for the past year. The nurse considers this finding as: :a.Normal b.Average c.Abnormal d.Too low prompting the need for a pacemaker

A Response Feedback: The range for heart rate in adults is 60-100 making a heart rate of 60 as normal. This heart rate is on the low end of normal, but it is still normal. Answer choice B is incorrect because 70 is an average heart rate in adults, not 60. Answer choice C is incorrect because 60 is normal, not abnormal. The same rationale applies to answer choice D: the heart rate is not too low because it falls in the normal range of 60-100.

For which person is a shift assessment indicated? a. The person who had abdominal surgery yesterday b. The person who is unaware of his high serum glucose levels c. The person who is being admitted to a long-term care facility d. The person who is beginning rehabilitation after a knee replacement

ANS: A A shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A screening assessment is performed for the purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is performed during admission to a facility to obtain a detailed history and complete physical examination. An episodic or follow-up assessment is performed after knee replacement to evaluate the outcome of the procedure.

When there is evidence that supports a screening for an individual patient but not for the general population, the nurse would expect the United States Preventive Services Task Force Grading (USPSTF) to be what? a. No recommendation for or against b. Recommends c. Recommends against d. Strongly recommends

ANS: A The USPSTF Grading is an example of how evidence is used to make guidelines and determine priority. When there is evidence that supports a screening for an individual patient but not for the general population, there is no recommendation for or against screening the general population. Recommends is the grading when there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Recommends against is the grading when there is moderate or high certainty that the intervention has no net benefit or that the harms outweigh the benefits. Strongly recommends is the grading when there is high certainty that the net benefit is substantial

1. Which statement or question does the nurse use during the introduction phase of the interview? a. "I'm here to learn more about the pain you're experiencing." b. "Can you describe the pain that you're experiencing?" c. "I heard you say that the pain is 'all over' your body." d. "What relieves the pain you are having?"

ANS: A "I'm here to learn more about the pain you're experiencing" is an example of the introduction phase a nurse may use to explain the purpose of the interview to a patient. "Can you describe the pain that you're experiencing?" is an example of part of a symptom analysis that occurs in the discussion phase. "I heard you say that the pain is 'all over' your body" is an example of a summary statement by the nurse that occurs in the summary phase. "What relieves the pain you are having?" is an example of part of a symptom analysis that occurs in the discussion phase.

During the history, the patient states that she does not use many drugs. What is the nurse's appropriate response to this statement? a. "Tell me about the drugs you are using currently." b. "To some people six or seven is not many." c. "Do you mean prescription drugs or illicit drugs?" d. "How often are you using these drugs?"

ANS: A "Tell me about the drugs you are using currently" is an open-ended question that allows patients to provide further data. "To some people six or seven is not many" is a comment that does not ask a question or obtain useful data. "Do you mean prescription drugs or illicit street drugs?" is a closed-ended question that yields data about the type of drugs used only. "How often are you using these drugs?" asks about frequency of drug use, which is not useful until the drugs are known.

A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The nurse suspects that the patient is noncompliant with her diet. Which response by the nurse enhances data collection in this situation? a. "Tell me about what foods you eat and the frequency of your meals." b. "What symptoms do you notice when your blood sugar levels are high?" c. "You need to follow what the doctor has prescribed to manage your disease." d. "Tell me what you know about the cause of type 2 diabetes."

ANS: A "Tell me about what foods you eat and the frequency of your meals" gathers more data from the patient to help the nurse confirm if noncompliance is the reason for the weight gain and high glucose levels. "What symptoms do you notice when your blood sugar levels are high?" does not help the nurse determine if the patient is noncompliant. It may be useful later when teaching the patient about her disease. "You need to follow what the doctor has prescribed to manage your disease" does not provide additional data for the nurse and may be viewed as authoritarian and paternalistic. "Tell me what you know about the cause of type 2 diabetes" assumes that the reason for the weight gain and high glucose levels is a lack of knowledge. A more therapeutic approach is to gather more data from the patient about how the diabetes has been managed

13. Which activity illustrates the concept of secondary prevention? a. Annual mammogram b. Nutrition classes on low-fat cooking c. Education on living with diabetes mellitus d. Cardiac rehabilitation after coronary artery bypass surgery .

ANS: A A mammogram screens for breast cancer and is an example of secondary prevention to promote early detection of disease. Nutrition classes are an example of primary prevention to prevent a disease from developing by promoting a healthy lifestyle. Education about diabetes mellitus is an example of tertiary prevention directed toward minimizing the disability from chronic disease and helping the patient maximize his or her health. Cardiac rehabilitation after coronary artery bypass surgery is an example of tertiary prevention directed toward minimizing the disability from chronic disease and helping the patient maximize his or her health

10. After collecting the data, the nurse begins data analysis with which action? a. Clustering data b. Documenting subjective data c. Reporting information to other health team members d. Documenting objective information

ANS: A After collecting data, the nurse organizes or clusters the data so that the problems appear more clearly. To cluster data, the nurse interprets the assessment data collected. Documenting subjective data is necessary for the medical record, but does not provide analysis. Before reporting data to health team members, the nurse clusters and interprets data. Documenting objective data is necessary for the medical record, but does not provide analysis

9. Which patient information does the nurse document in the patient's physical assessment? a. Slurred speech b. Immunizations c. Smoking habit d. Allergies

ANS: A Slurred speech should be noticed by the nurse and documented as objective data in the physical assessment. Data on immunizations are collected from the patient, are subjective, and documented in the history. A smoking habit is information that comes from the patient, making it subjective data that is documented in the history. Allergies are information that come from the patient, making it subjective data that is documented in the history.

7. Which is an example of data a nurse collects during a physical examination? a. The patient's lack of hair and shiny skin over both shins b. The patient's stated concern about lack of money for prescriptions c. The patient's complaints of tingling sensations in the feet d. The patient's mother's statements that the patient is very nervous lately

ANS: A The lack of hair and shiny skin over both shins are objective data or signs that are part of the physical examination. A patient's concerns about lack of money are subjective data and are part of the health history. A patient's complaints of tingling sensations in the feet are subjective data and are part of the health history. A patient's family statements are considered secondary data, are subjective data, and are part of the health history.

According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patient's upper arms? a. Ankle b. Thigh c. Calf d. Wrist

ANS: A Feedback A A study comparing accuracy among sites recommended the ankle as an alternative site for blood pressure measurement. B The thigh is an alternative site, but the ankle is the preferred site. C A study comparing accuracy among sites recommended the ankle site in preference to the calf as an alternative site for blood pressure measurement if the upper arm is unavailable. D Approaches to measuring blood pressure using the wrist and finger sites have been developed, but these lack acceptable accuracy and cost efficiency to be recommended for clinical practice.

Which patient would be expected to experience acute pain? a. A patient who had abdominal surgery 8 hours ago b. A patient who has cancer and has been receiving treatment for 4 months c. A patient who states that he or she has lived with severe pain for many years d. A patient who has been treated unsuccessfully over the past year for back pain

ANS: A Feedback A Acute pain has a recent onset and results from tissue damage; is usually selflimiting; and ends when the tissue heals. B Acute pain has a recent onset and results from tissue damage; is usually selflimiting; and ends when the tissue heals. C This patient has experienced chronic pain for years. Acute pain has a recent onset and results from tissue damage; is usually self-limiting; and ends when the tissue heals. D This patient has experienced chronic pain for one year. Acute pain has a recent onset and results from tissue damage; is usually self-limiting; and ends when the tissue heals.

A patient admitted to the emergency department with "excruciating chest pain, above the rating of 10," has a heart rate of 55, rapid, irregular respirations, complains of nausea, and is too weak to move to the stretcher without aid. The nurse recognizes that this response to severe pain is due to the response of the _____ nervous system. a. Parasympathetic b. Sympathetic c. Central d. Peripheral

ANS: A Feedback A During severe or deep pain the parasympathetic nervous system may cause pallor; rapid, irregular breathing; nausea; and vomiting. B The sympathetic nervous system responds to acute pain by increasing heart rate, increasing blood pressure, causing diaphoresis, increasing respiratory rate, increasing muscle tension, dilating pupils, and decreasing gastrointestinal motility. C The central nervous system includes the brain and spinal cord. The manifestations described in the case are due to parasympathetic nervous system stimulation. D The manifestations described in the case are due to parasympathetic nervous system stimulation

The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation? a. The measurement at 6 AM b. The measurement at 12 PM c. The measurement at 6 PM d. The measurement at 12 AM

ANS: A Feedback A Early in the morning is the time of the lowest temperature of the day due to circadian rhythms. B A low temperature due to circadian rhythms is not expected at this time. C The highest temperature occurs in the late afternoon and early evening due to circadian rhythms. D A low temperature due to circadian rhythms is not expected at this time

8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's temperature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate? a. The patient's temperature b. The patient's oxygen saturation c. The patient's pulse rate d. The patient's blood pressure

ANS: A Feedback A Fever is a factor that may increase respiratory rate, and this patient's temperature is 102° F. B The patient's oxygen saturation is a measure of the oxygen carried by hemoglobin and it is within expected limits—above 90%. C The patient's pulse rate may be due to the high temperature, but a pulse of 100 does not contribute to an elevated respiratory rate in this case. D The patient's blood pressure is higher than normal, but does not contribute to an elevated respiratory rate in this case

A temperature of 99.8° F taken in the axilla is equivalent to which temperature value taken orally? a. 100.8° F b. 99.8° F c. 98.8° F d. 97.8° F

ANS: A Feedback A Normal temperature readings from the axilla are about 1° F below the normal oral temperature. B Normal temperature readings from the axilla are about 1° F below the normal oral temperature. C Normal temperature readings from the axilla are about 1° F below the normal oral temperature. D Normal temperature readings from the axilla are about 1° F below the normal oral temperature

In the labor and delivery department, the nurse notices that two women who are in labor are responding differently to their contractions. The first woman, who is having her first baby, has rated her pain as a "7," seems agitated, and has asked for pain medication. The second woman, who is having her third baby, has also rated her pain as a "7," but is calmer and says she does not need anything for pain at this time. What explains the differences in the outward responses to pain between these women? a. Pain tolerance b. Pain threshold c. Nociception d. Physiologic stress

ANS: A Feedback A Pain tolerance is the duration or intensity of pain a person will endure before outwardly responding. A person's culture, pain experience, expectations, role behaviors, and physical and emotional health influence pain tolerance. The second woman had experienced the birth process before and had different expectations than the first woman, who was having her first baby. B Pain threshold is the point at which a stimulus is perceived as pain. This threshold does not vary significantly among people or in the same person over time. C Nociception is the process of pain perception and involves transduction, transmission, perception, and modulation. D Physiologic stress stimulates the sympathetic nervous system causing tachycardia, increased respiratory rate, and dilated pupils, but does not necessarily affect pain response.

How does the nurse detect an extra heart sound in an adult? a. Using the bell of a stethoscope b. With a pulse oximeter c. Using the diaphragm of a stethoscope d. With a Doppler ultrasound probe

ANS: A Feedback A The bell of the stethoscope is used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit). B Pulse oximetry is a noninvasive measurement of arterial oxygen saturation in the blood. C The diaphragm is used to hear high-pitched sounds such as breath sounds, bowel sounds, and normal heart sounds. D A Doppler ultrasound probe is used to detect difficult-to-hear vascular sounds such as fetal heart tones or peripheral pulses.

While assessing a patient's lower extremities, the nurse suspects the lower extremities feel cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the temperatures of the lower extremities with the upper extremities? a. Using the backs (dorsum) of the hands to detect differences b. Using the ulnar surface of the hands to detect differences c. Using the pads of the fingers to detect differences d. Using the palmar surface (underside) of the hands to detect differences

ANS: A Feedback A The dorsal surfaces of the hands detect temperature best. B The ulnar surfaces of the hands are the most sensitive to vibration. C The pads of the fingers are used in palpation. D The palmar surfaces (underside) of the fingers and finger pads are better for determining position, texture, size, consistency, masses, fluid, and crepitus.

The nurse taking a patient's blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? Select all that apply. a. The patient rates pain at a level of 7 on a scale of 0 to 10. b. The cuff was reinflated before being completely deflated. c. The patient drank cold milk just before the reading. d. The time of day is late afternoon. e. The cuff is too wide for the extremity.

ANS: A, B, D Correct: Rating pain at a level of 7 on a scale of 0 to 10, reinflating the cuff before being completely deflated, and taking the reading in late afternoon are all factors that can increase blood pressure. Incorrect: Drinking cold milk just before the reading will not affect blood pressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuff makes the reading lower than it actually is rather than higher.

The nurse is performing a symptom analysis of a patient with pain. Which questions below are appropriate for a symptom analysis? Select all that apply. a. "Have you had any other symptoms such as nausea, vomiting, and sweating?" b. "Where is the pain located?" c. "Have you had a pain like this before?" d. "What does the pain feel like?" e. "What do you do to make your pain better?" f. "In your culture, how are you encouraged to express your pain?"

ANS: A, B, D, E Correct: "Have you had any other symptoms such as nausea, vomiting, and sweating?" "Where is the pain located?" "What does the pain feel like?" "What do you do to make your pain better?" These four questions are asked in a symptom analysis that includes the following variables: onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, self-treatment, and severity. Incorrect: "Have you had a pain like this before?" This question relates to the patient's health history. "In your culture, how are you encouraged to express your pain?" This question relates to the patient's culture and does not help analyze the patient's pain experience.

Which data do nurses document under the heading of Personal and Psychosocial History? (Select all that apply.) a. Walks for 45 minutes each day b. Eats meats, vegetables, and fruit at two meals daily c. Is allergic to milk and milk products d. Is married and has two daughters whom he is close to e. Smokes marijuana once a week f. Grandfather died from prostate cancer

ANS: A, B, D, E Walks for 45 minutes each day is documented under health promotion activity in Personal and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is documented about diet activity in Personal and Psychosocial History; is married and has two daughters whom he is close to is documented under family and social relationship activity in Personal and Psychosocial History; smokes marijuana once a week is documented under personal habits activity in Personal and Psychosocial History. Allergic to milk and milk products is an allergy, which is documented under the heading Present Health Status; Grandfather died from prostate cancer is documented under the heading Family History.

Which action by the nurse results in the patient's blood pressure measurement being falsely low? Select all that apply. a. Using a blood pressure cuff that is too wide for the patient's arm b. Not inflating the blood pressure cuff enough c. Positioning the patient's arm above the level of the heart d. Wrapping the cuff too loosely around the arm e. Deflating the cuff too rapidly

ANS: A, B, E Correct: Using a blood pressure cuff that is too wide for the patient's arm, not inflating the blood pressure cuff enough, and deflating the cuff too rapidly could result in a false low reading. Incorrect: Positioning the patient's arm above the level of the heart and wrapping the cuff too loosely around the arm causes the blood pressure to be falsely high.

Which method of temperature measurement does a nurse choose when assessing children? Select all that apply. a. Axillary temperature b. Rectal temperature c. Temporal artery temperature d. Oral temperature e. Tympanic membrane temperature

ANS: A, C, D, E Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children. Incorrect: Rectal temperature measurement is considered safe and accurate for adults only.

3. How do nurses assess pain of neonates or of adults with dementia or decreased level of consciousness? Select all that apply. a. Ask family or caregivers what indicators they think may indicate the patient's pain. b. Review results of blood tests for signs of pain. c. Administer the ordered analgesic to the patient. d. Identify any physiologic signs of pain. e. Examine the patient for possible causes of pain.

ANS: A, C, D, E Correct: These four answers are the clinical practice recommendations of Herr and colleagues. Incorrect: Pain cannot be detected with laboratory tests

Which action by the nurse results in the patient's blood pressure measurement being falsely high? Select all that apply. a. Using a blood pressure cuff that is too narrow for the patient's upper arm b. Deflating the blood pressure cuff too rapidly c. Wrapping the blood pressure cuff too loosely d. Reinflating the blood pressure cuff before it completely deflates e. Positioning the patient's arm above the level of the heart

ANS: A, C, D, E Correct: Using a blood pressure cuff that is too narrow for the patient's upper arm, wrapping the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the patient's arm above the level of the heart all result in readings that are falsely high. Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low.

Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports breathing problems? (Select all that apply.) a. How long have you had this problem with your breathing? b. Do you have a family history of breathing problems? c. Does this breathing problem come and go or is it constant? d. What do you do to make your breathing better? e. How does this breathing problem affect your work or daily activities? f. How many packs of cigarettes do you smoke a day?

ANS: A, C, D, E How long have you had this problem with your breathing?, Does this breathing problem come and go or is it constant?, What do you do to make your breathing better?, and How does this breathing problem affect your work or daily activities? are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms). Do you have a family history of breathing problems? This question relates to the patient's history; How many packs of cigarettes do you smoke a day? This question relates to the patient's history.

Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports a headache? (Select all that apply.) a. Describe what the headache feels like. b. When was your last eye examination? c. What makes the headaches worse? d. How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)? e. Do you have any symptoms with the headaches, such as nausea? f. When did you first notice the headaches?

ANS: A, C, D, E, F Describe what the headache feels like?, What makes the headaches worse?, How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?, Do you have any symptoms with the headaches, such as nausea?, and When did you first notice the headaches? are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms). When was your last eye examination? assumes that the headaches are related to a vision problem. Last eye examination is documented in the history under the heading of Past Health History.

A nurse is assessing a patient who complains of "awful" abdominal pain and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? Select all that apply. a. Tachycardia b. Irritability c. Increased blood pressure d. Depression e. Insomnia f. Sweating

ANS: A, C, F Correct: The sympathetic nervous system responds to acute pain by increasing heart rate, increasing blood pressure, causing diaphoresis, increasing respiratory rate, increasing muscle tension, dilating pupils, and decreasing gastrointestinal motility. Incorrect: Irritability, depression, and insomnia are manifestations of chronic rather than acute pain.

The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min. a. 16-month-old; 36 b. 6-year-old; 20 c. 14-year-old;26 d. 40-year-old; 10

ANS: B A A toddler's respiratory rate ranges from 24 to 32. B A school-age child's respiratory rate ranges from 18 to 26. C An adolescent's respiratory rate ranges from 12 to 16. D An adult's respiratory rate ranges from 12 to 20.

What does the nurse say to obtain more data about a patient's vague statement about diet such as, "My diet's okay"? a. "Eating a variety of meats, fruits, and vegetables each day is important." b. "Give me an example of the foods you eat in a typical day." c. "Go on." d. "Does your diet meet your needs or does it need improvement?"

ANS: B "Give me an example of the foods you eat in a typical day." This statement asks the patient to clarify the vague statement, "My diet is okay." "Eating a variety of meats, fruits, and vegetables each day is important." While this statement is true, it does not obtain data about what foods the patient consumes. "Go on" encourages patients to continue talking, but does not help clarify what foods are consumed. "Does your diet meet your needs or does it need improvement?" This response does not help clarify what foods the patient eats. Also it contains two questions rather than asking one question at a time.

An example of a health promotion question included in the health history is: a. "Do you have any allergies?" b. "How often are you exercising?" c. "What are you doing to relieve your leg pain?" d. "What kind of herbs are you using?"

ANS: B "How often are you exercising?" is a question about activities patients regularly perform to maintain health. "Do you have any allergies?" is a question for the present health status rather than health promotion. "What are you doing to relieve your leg pain?" is a question that is part of the symptom analysis. "What kind of herbs are you using?" is a question for the present health status rather than health promotion

Which situation illustrates a screening assessment? a. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination. b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons. c. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg pain. d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.

ANS: B A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a screening assessment focused on disease detection. A detailed history and physical examination conducted during a first-time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area of an urgent care center is an example of a problem-based/focused assessment. A patient's return appointment 1 month after today's office visit to report fasting blood glucose levels is an example of an episodic or follow-up assessment.

For which patient is a focused health history most appropriate? a. A new patient at the health clinic for an annual examination b. A patient admitted to the hospital with vomiting and abdominal pain c. A patient at the health care provider's office for a sport physical d. A patient discharged 11 months ago who is being readmitted today

ANS: B A patient admitted to the hospital with vomiting and abdominal pain benefits from a focused health history that limits data to the immediate problem. A new patient at the health clinic for an annual examination needs a comprehensive history that includes biographic data, reason for seeking care, present health status, past medical history, family history, personal and psychosocial history, and a review of all body. A patient with a specific need, such as a sport physical, needs a history for an episodic assessment. A patient discharged months ago who is being readmitted needs a history for a follow-up assessment that generally focuses on the specific problem or problems that caused the patient to be readmitted

3. For which person is a screening assessment indicated? a. The person who had abdominal surgery yesterday b. The person who is unaware of his high serum glucose levels c. The person who is being admitted to a long-term care facility d. The person who is beginning rehabilitation after a knee replacement

ANS: B A screening assessment is performed for the purpose of disease detection. In this case this person may have diabetes mellitus. A shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A comprehensive assessment is performed during admission to a facility to obtain a detailed history and complete physical examination. An episodic or follow-up assessment is performed after knee replacement to evaluate the outcome of the procedure

What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? a. Clean the bell and diaphragm of the stethoscope between patients. b. Perform hand hygiene. c. Wear gloves when anticipating exposure to body fluids. d. Wear eye protection when anticipating spatter of body fluids.

ANS: B Feedback A Cleaning the bell and diaphragm of the stethoscope between patients is important to prevent the spread of microorganisms when auscultating only. B Consensus recommendations of the World Health Organization include use of hand hygiene techniques to prevent spread of microorganisms before palpating, percussing, or auscultating patients, and during patient care. C Wearing gloves when anticipating exposure to body fluids is important to prevent the spread of microorganisms from the patient while giving care. D Wearing eye protection when anticipating spatter of body fluids is important to prevent the spread of microorganisms from the patient while giving care

Which tertiary prevention measure should be included in the health promotion plan of care for a patient newly diagnosed with diabetes? a. Avoiding carcinogens b. Foot screening techniques c. Glaucoma screening d. Seat belt use

ANS: B Foot screening is considered a tertiary prevention measure, one that minimizes the problems with foot ulcers, an effect of diabetic disease and disability. Avoiding carcinogens is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Glaucoma screening is considered secondary screening—measures designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Seat belt use is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity

14. A community organization sponsors a health fair to increase awareness of colon cancer. At the health fair, colorectal cancer screening kits are distributed, and health care professionals answer questions, take blood pressure, and distribute literature. What level of health prevention is being implemented by this community organization? a. Primary b. Secondary c. Tertiary d. Risk factor

ANS: B Secondary prevention consists of screening efforts to promote early detection of disease — in this scenario, colorectal cancer and hypertension. Primary prevention is focused on preventing disease from developing through the promotion of a healthy lifestyle. Tertiary prevention is directed toward minimizing the disability from chronic disease and helping the patient maximize his or her health. Risk factor prevention is part of primary prevention that focuses on preventing disease by managing risk factors

A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes? a. Past health history b. Present health status c. Reason for seeking care (chief complaint) d. History of present illness

ANS: B The present health status documents the current health conditions, which include chronic diseases and medications taken. In this case, diabetes and taking insulin are not the reason for seeking care, but need to be managed while the patient's pneumonia is being treated because they may affect the patient's recovery from pneumonia. The past health history includes categories of childhood illness, surgeries, hospitalizations, accidents or injuries, immunizations, and obstetric history. The reason for seeking care (chief complaint) is a brief statement of the patient's purpose for requesting the services of a health care provider. History of present illness further investigates the history of the present problem; best accomplished by conducting a symptom analysis

Which statement is appropriate to use when beginning an interview with a new patient? a. "Have you ever been a patient in this clinic before?" b. "What is your purpose for coming to the clinic today?" c. "Tell me a little about yourself and your family." d. "Did you have any difficulty finding the clinic?"

ANS: B "What is your purpose for coming to the clinic today?" is an open-ended question that focuses on the patient's reason for seeking care. "Have you ever been a patient in this clinic before?" is a close-ended question that yields a "yes" or "no" response. This question may be asked on the first visit, but not as an opening question for a health interview. "Tell me a little about yourself and your family" is an open-ended question, but it is too general, and it is at least two questions: one about the patient and another about the family. "Did you have any difficulty finding the clinic?" is a social question and does not focus on the patient's purpose for the visit.

A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid? a. 1 L b. 5 L c. 11 L d. 24 L

ANS: B Feedback A Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. B Every kilogram (kg) equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. C Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. D Every kg equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L. This answer is obtained by multiplying 11 by 2.2 instead of dividing

A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is 5 inches wide and the patient's upper arm circumference is 20 inches. How accurate will this patient's blood pressure be using this blood pressure cuff? a. Accurate, the actual value b. Higher than the actual value c. Lower than the actual value d. Unable to determine accuracy with available data

ANS: B Feedback A For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches (20 0.40 = 8). Therefore the blood pressure measurement will not be accurate. B For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches (20 0.40 = 8). The cuff is 5 inches, which is too narrow. A cuff that is too narrow will overestimate the blood pressure and report a falsely high value. C For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches (20 0.40 = 8). Therefore the blood pressure measurement will be higher than the actual value. D Sufficient data provided to determine accuracy. For an arm circumference that is 20 inches, the proper size cuff is at least 8 inches (20 0.40 = 8).

Which explanation is most appropriate for a nurse preparing to palpate a patient's neck? a. "I need to feel for tumors in your neck." b. "I'm going to feel your neck for any abnormalities." c. "I need to press deeply on your neck so please hold still." d. "Is there any tenderness in your neck?"

ANS: B Feedback A I need to feel for tumors in your neck" uses the term "tumors" and may alarm the patient unnecessarily. B Palpating the neck enters the patient's personal space and may have cultural significance. Thus it is important to inform patients of the impending action and its purpose. C "I need to press deeply on your neck so please hold still" may alarm the patient and is not accurate. To palpate the neck, light palpation is used to detect abnormalities such as enlarged nodes. Deep palpation is used on the abdomen. D "Is there any tenderness in your neck?" obtains subjective data, but does not tell the patient what the nurse is planning to do.

A patient with gout is complaining of severe, throbbing pain in the great toe. What type of pain is this patient experiencing? a. Neuropathic pain b. Somatic pain c. Referred pain d. Visceral pain

ANS: B Feedback A Neuropathic pain is caused by abnormal processing of sensory input from the peripheral nervous system. B Somatic pain arises from bone, joint, muscle, skin, or connective tissues and is usually aching or throbbing in quality and well located. C Referred pain is pain felt at a site different from that of an injured or diseased organ. D Visceral pain occurs with obstruction of a hollow organ and causes intermittent cramping pain.

A patient has had chronic back pain for several years. On assessment, the nurse notes that the patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be in pain. When questioned, the patient rates the pain as a 6 on a scale of 0 to 10. How does the nurse interpret these data? a. Many patients cannot be believed when they complain of severe pain lasting many months. b. Patients may not have the same objective responses to chronic pain because of compensation over time. c. The patient probably has already taken a very effective pain medication. d. This patient is probably not having as much pain as reported initially, and more assessment is required.

ANS: B Feedback A Pain is whatever the patient says it is. Patients with chronic pain adapt to the pain and have more subtle manifestations than patients with acute pain. B Clinical manifestations of chronic pain are not those of physiologic stress because the patient adapts to the pain. C Patients with chronic pain adapt to the pain and have more subtle manifestations than patients with acute pain despite the effects of pain medication. D Pain is whatever the patient says it is. Patients with chronic pain adapt to the pain and have more subtle manifestations than patients with acute pain.

Which assessment technique is appropriate to measure the 8-month-old's vital signs during a well-baby check? a. Assess temperature using a rectal thermometer. b. Observe the infant's abdomen when counting respirations. c. Take the infant from the parent's arms to assess pulse. d. Measure blood pressure in the leg.

ANS: B Feedback A Rectal temperatures should be taken as a last resort because children tend to fear intrusive procedures and because of the risk for rectal perforation. The recommended sites for temperature measurement in newborns, infants, and children to age 5 are the axillary or tympanic sites. B Infants usually breathe diaphragmatically, which requires observation of abdominal movement. C For the older infant ( 6 months) and toddler, the nurse may find that having the caregiver hold the baby or toddler decreases fear and distress, thus making it easier for the nurse to conduct the examination. D This infant is too young for blood pressure measurement. The National High Blood Pressure Education Program recommends that blood pressure be measured in children from age 3 through adolescence as part of routine health care visits.

In performing a respiratory assessment of a 1-month-old infant, the nurse recognizes which finding as abnormal? a. Sneezing b. Coughing c. Abdominal breathing d. Predominantly nose breathing

ANS: B Feedback A Sneezing is a common finding for an infant and is therapeutic because it helps to clear the nose. B Coughing at this age is considered abnormal and indicates a problem. C Infants use abdominal breathing rather than diaphragmatic breathing. D Infants are obligate nose breathers until about 3 months old.

Which statement is correct regarding taking or interpreting axillary temperatures? a. Axillary temperatures should not be used in patients less than 2 years of age. b. Readings may be less accurate. c. The thermometer is left in place for no more than 3 minutes. d. The thermometer is placed in the axilla with the shoulder abducted.

ANS: B Feedback A The axilla is a common site for temperature measurement on infants and children. B Multiple studies have shown temperature measurements at the axillary site are less accurate compared with alternative sites. C The thermometer is left in place until the audible signal occurs and the temperature appears on the screen. D Place the probe in the middle of the axilla, with the arm held against the body (adducted).

Which patient has pain caused by abnormal processing of sensory input from the peripheral nervous system? a. The patient who has aching pain from muscle strain b. The patient who has burning pain along the sciatic nerve c. The patient who has cramping pain from a tumor in the colon d. The patient who has throbbing pain from arthritis

ANS: B Feedback A The patient who has aching pain from muscle strain has nociceptor, somatic pain. B The patient who has burning pain along the sciatic nerve has neuropathic pain. C The patient who has cramping pain from a tumor in the colon has nociceptor, visceral pain. D The patient who has throbbing pain from arthritis has nociceptor, somatic pain.

During a well-baby check for several 4-month-old infants, a nurse recognizes that which infant needs further assessment of an abnormal finding? a. The infant who is unable to sit independently b. The infant whose head circumference and chest circumference are equal c. The infant whose weight has doubled since birth d. The infant whose length falls in the 90th percentile on growth charts .

ANS: B Feedback A This is not an expected motor skill for a 4-month-old; it is expected at 6 months of age. B At four months of age, the head circumference should be larger than the chest circumference. C This is a normal finding; infants generally double their birth weight by age 4 to 5 months. D This is not an abnormal finding, especially if weight is normal; the height of the parents should also be considered

11. The nurse is unable to hear the patient's breath sounds. What checks does the nurse make of the stethoscope to determine the cause of this problem? a. Ensure the stethoscope tubing is at least 20 inches long. b. Ensure the valve is open to the diaphragm on the head of the stethoscope. c. Ensure the earpieces are pointed toward the back of the ears. d. Ensure the bell is placed firmly against the patient's skin.

ANS: B Feedback A Tubing should be no longer than 12 to 18 inches. If the tubing is longer than 18 inches, the sounds may become distorted. B The diaphragm is used to hear high-pitched sounds, such as breath sounds, bowel sounds, and normal heart sounds. Its structure screens out low-pitched sounds. C Earpieces are angled toward the nose so that sound is projected toward the tympanic membrane. D The bell of the stethoscope is used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit)

When examining a patient, the nurse remembers to follow which principle of Standard Precautions? a. Wear gloves throughout the entire examination of the patient. b. Wear gloves when in contact with the patient's mucous membranes. c. Wear gloves to reduce the need for handwashing. d. Wear eye protection and a gown during the examination of the patient.

ANS: B Feedback A Wearing gloves throughout the examination of the patient is unnecessary. Referring to the Standard Precautions for the correct answer; nurses use judgment to determine when contact with body fluids is possible. B Specifically, this applies to contact with blood, body fluids (e.g., urine, feces, sputum, wound drainage), nonintact skin, and mucous membranes. C Hands must be washed after removal of gloves. D The nurse should wear a mask with eye protection or a face shield during procedures that may result in splashes or sprays of the patient's blood, body fluids, secretions, or excretions.

Which questions are pertinent for a nurse to ask a patient while performing a review of the cardiovascular system? (Select all that apply.) a. Do you remember what your last cholesterol value was? b. Have you had chest pain or shortness of breath? c. Do you have trouble breathing when you lie down? d. Are your feet cold, numb, or do they change color? e. How much do you weigh? f. Have you noticed edema in your ankles at the end of the day?

ANS: B, C, D, F Have you had chest pain or shortness of breath?, Do you have trouble breathing when you lie down?, Are your feet cold, numb, or do they change color?, and Have you noticed edema in your ankles at the end of the day? are questions asked to give the patient an opportunity to report symptoms of the cardiovascular system. Do you remember what your last cholesterol value was? relates to a lab value, which is objective data not documented in the history; How much do you weigh? is objective data not documented in the history

Which data do nurses document under the heading of Past Health History? (Select all that apply.) a. Father has Alzheimer disease. b. Last tetanus in 2009 c. Had chicken pox as a child d. Drinks three to four beers each day e. Had a dental examination 6 months ago

ANS: B, C, E Last tetanus is an immunization, chicken pox as a child is a childhood illness, and last examinations, including dental, are documented under the heading of Past Health History. Family History documents father's Alzheimer disease; patient drinking three to four beers each day refers to alcohol use, which is documented under the heading Personal and Psychosocial History.

Which method of temperature measurement indirectly reflects inner core temperature? Select all that apply. a. Axillary temperature b. Oral temperature c. Tympanic temperature d. Rectal temperature e. Temporal artery temperature

ANS: B, E Correct: Inner core temperature is measured indirectly because the probe is placed near an artery. For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature. Incorrect: For axillary, tympanic, and rectal temperatures, the probe is not placed close to any major blood vessels.

For which person is a comprehensive assessment indicated? a. The person who had abdominal surgery yesterday b. The person who is unaware of his high serum glucose levels c. The person who is being admitted to a long-term care facility d. The person who is beginning rehabilitation after a knee replacement

ANS: C A comprehensive assessment is performed during admission to a facility to obtain a detailed history and complete physical examination. A shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A screening assessment is performed for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-up assessment is performed after knee replacement to evaluate the outcome of the procedure.

Which statement by the nurse demonstrates a patient-centered interview? a. "I need to complete this questionnaire about your medical and family history." b. "The hospital requires me to complete this assessment as soon as possible." c. "Tell me about the symptoms you've been having." d. "I've had the same symptoms that you've described."

ANS: C "Tell me about the symptoms you've been having" focuses on the needs of the patient so that the patient is free to share concerns, beliefs, and values in his or her own words. "I need to complete this questionnaire about your medical and family history" focuses on the nurse's need to complete the assessment rather than the needs of the patient. "The hospital requires me to complete this assessment as soon as possible" focuses on the nurse's need to meet hospital requirements rather than the needs of the patient. "I've had the same symptoms that you've described" focuses on the nurse rather than on the patient.

When teaching a patient withNa family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary

ANS: C Blood pressure screening is considered secondary prevention. It is a measure designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Illness prevention is considered primary prevention. Primary prevention measures are those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Tertiary prevention measures are those that minimize the effects of disease and disability.

Which nursing behaviors indicate culturally competent care? a. Recognizing that there are different definitions of health and illness b. Complying with the stated plan of treatment despite the patient's differing opinion c. Understanding that there is diversity even among people of the same cultural group d. Helping patients of different cultures adopt the beliefs and behaviors of the dominant culture

ANS: C Feedback A Recognizing that there are many different definitions of health and illness is not sufficient for culturally competent care. B Complying with the stated plan of treatment despite the patient's differing opinion is not a culturally competent behavior. The patient needs to understand, support, and participate in the plan of care. C Understanding that there is diversity even among people of the same cultural group prevents assumptions and stereotypes that inhibit culturally competent care. D Helping patients of different cultures adopt the beliefs and behaviors of the dominant culture is an example of the opposite of cultural competence; it assumes that all persons should adopt certain beliefs and behaviors

12. A nurse is teaching a patient how to manage chronic obstructive pulmonary disease (COPD). This intervention is an example of which level of health promotion? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention

ANS: C Teaching a patient how to live with a chronic disease is an example of tertiary prevention directed toward minimizing the disability from chronic disease and helping the patient maximize his or her health. The focus of primary prevention is to prevent a disease from developing by promoting a healthy lifestyle. Secondary prevention consists of efforts to promote early detection of disease. Risk factor prevention is part of primary prevention that focuses on preventing disease by managing risk factors

A patient tells the nurse at the clinic, "I can never seem to get warm lately and feel tired all the time." The nurse records these data under which section of the health history? a. Past health history b. Present health status c. Reason for seeking care (chief complaint) d. Subjective assessment data

ANS: C The reason for seeking care (chief complaint) is the patient's reason for seeking care (also called the presenting problem). The patient's reason for seeking care is often recorded as a direct quote. The past health history includes data about immunizations, surgeries, accidents, and childhood illnesses. The present health status includes data the nurse obtains from the patient, often using a symptom analysis in which more data are collected about the patient's reason for seeking care. Subjective assessment data include information from the patient. In this example, the patient expresses the reason for seeking care, which is directly quoted and placed in quotation marks in the chief complaint section of the data sheet so that the patient's reason for seeking care can be easily identified.

A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, "How I can be feeling pain in my foot—my foot is gone!" What is the appropriate response from the nurse? a. "After your amputation, pain perception increases." b. "Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system." c. "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there." d. "When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located."

ANS: C Feedback A "After your amputation, pain perception increases" is a definition of pain threshold. B "Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system" is a definition of neuropathic pain. C "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there" is a definition of phantom pain. D "When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located" is a definition of referred pain

How does a nurse document a large, flat bluish capillary area on a neonate's cheek? a. Mongolian spot b. Stork bite (telangiectasis) c. Port-wine stain (nevus flammeus) d. Strawberry hemangioma

ANS: C Feedback A A Mongolian spot appears as an irregularly shaped, darkened, flat area over the sacrum and buttocks. B A stork bite (telangiectasis) is a common vascular birthmark that appears as a small red or pink spot often seen on the back of the neck. C Port-wine stains appear as large, flat, bluish purple capillary areas. They are frequently found on the face along the distribution of the fifth cranial nerve (trigeminal). D A strawberry hemangioma appears as a slightly raised, reddened area with a sharp demarcation line that may be 2 to 3 cm in diameter.

A patient's blood pressure has been averaging 120/72 when using the upper arms. Today the nurse uses this patient's thigh to measure the blood pressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120? a. A systolic reading of 110 mm Hg b. A systolic reading of 120 mm Hg c. A systolic reading of 140 mm Hg d. A systolic reading of 170 mm Hg

ANS: C Feedback A A systolic reading of 110 mm Hg is too low. B A systolic reading of 120 mm Hg is too low. C Normally the systolic blood pressure is 10 to 40 mm Hg higher in the leg than in the arm. D A systolic reading of 170 mm Hg is too high.

A nurse refers which child for further assessment? a. A 2-year-old who has a jugular venous hum after playing b. A 4-year-old who has a resting heart rate of 100 c. A 5-year-old who positions herself in a squat after running a few feet d. A 7-year-old who has a strong femoral pulse readily detected on palpation .

ANS: C Feedback A An expected finding in children is a venous hum in the jugular vein. B This is an expected resting heart rate for a child; the expected range for a toddler is from 80 to 110 and for a school-age child from 60 to 110 beats/min. C Squatting may be a compensatory position for a child with a heart defect. D This is an expected finding

The nurse suspects an irregularity in the rhythm of the patient's radial pulse. What is the most appropriate action for this nurse to take at this time? a. Document this rhythm as normal for the patient. b. Use a Doppler to check the brachial pulse. c. Count the patient's apical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4.

ANS: C Feedback A An irregular rhythm is not a normal finding. The pulsation between each beat should be the same or regular. B A Doppler is not indicated in this case; it is used when the pulse cannot be palpated. C When an irregular pulse is palpated, the nurse counts the number of pulsations for a full minute. D Counting the radial pulse again for 15 seconds and multiplying by 4 may reconfirm the initial findings, but does not provide additional data for the nurse on this patient

How does a nurse assess for fluid in a patient's abdomen? a. Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index finger of the pleximeter with the pad of the middle finger of the dominant hand b. Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor c. Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed, and striking that finger with the tip of the middle finger of the dominant hand d. Using direct percussion by placing one hand over the abdomen and striking lightly with the other hand

ANS: C Feedback A Only the finger being struck touches the area to be percussed; the other fingers are raised off the skin and the middle finger is struck with the tip of the finger of the other hand. B Percussing the abdomen requires both hands, one as the plexor and the other as the pleximeter. C Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed, and striking that finger with the tip of the middle finger of the dominant hand describes the correct technique. D Using direct percussion by placing one hand over the abdomen and striking lightly with the other hand does not describe the correct technique.

Which disorder, if any, does a nurse screen for when examining a healthy adolescent? a. Muscle weakness b. Limited joint range of motion c. Curvature of the spine d. No screening is needed when the adolescent is healthy

ANS: C Feedback A Screening for muscle weakness in a well adolescent is not indicated. B Screening for limited range of motion in a well adolescent is not indicated. C Adolescents are screened for scoliosis, kyphosis, and lordosis. Postural kyphosis is almost always accompanied by a compensatory lordosis, an abnormally concave lumbar curvature. D Adolescents are screened for scoliosis.

What part of the stethoscope do nurses use to auscultate the chest? a. Press the bell firmly against the skin to hear sounds and vibrations. b. The bell of the stethoscope is used to hear breath sounds. c. The diaphragm of the stethoscope is used to hear heart sounds. d. Either the bell or the diaphragm is used to auscultate the chest. .

ANS: C Feedback A The bell should be pressed lightly on the skin with just enough pressure to ensure that a complete seal exists around the bell. If the bell is pressed too firmly on the skin, the concave surface is filled with skin, and the bell functions like a diaphragm and inhibits vibrations. B The bell is used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit). C The diaphragm is used to hear breath sounds, bowel sounds, and normal heart sounds (high-pitched sounds). D Either the bell or the diaphragm is used to auscultate the chest. The diaphragm is used to hear breath sounds, bowel sounds, and normal heart sounds (high-pitched sounds)

Which nurse is performing the technique of light palpation appropriately? a. Nurse A applies the bimanual technique to determine size and location of the patient's heart. b. Nurse B uses the fingertips to feel for temperature differences on the patient's legs. c. Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations. d. Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.

ANS: C Feedback A The bimanual technique is used to entrap an organ or mass (such as the uterus or a growth) between the fingertips to determine size and location and is not palpation. B Temperature differences are best detected using the dorsal surface of the hand; this technique is not palpation. C Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations. This is considered a light palpation. D Light pulsation is performed by pressing in to a depth of approximately 1 cm, rather than 4 cm

How does a nurse collect baseline measurements of a 6-month-old infant? a. Measure the chest circumference around the lower ribs. b. Ask the parent how much the infant's weight has changed since birth. c. Measure the head just above the ears and eyebrows. d. Ask the parent to hold the infant while the nurse measures the length.

ANS: C Feedback A The nurse measures chest circumference, but the tape measure is placed around the nipples rather than the ribs. B An infant platform scale covered with a paper drape is used for weighing newborns, infants, and small children. C The nurse measures head circumference using this procedure until about 2 years old. D An infant's height is measured while the infant is lying supine.

A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a scale of 0 to 10. The nurse completes an assessment of this patient's pain and agrees to give pain medication. When the nurse returns to the patient with the ordered intravenous pain medication, she notices the patient's eyes are closed and he appears to be sleeping. What is the nurse's appropriate action at this time? a. Lock up the medication in a safe location until the patient awakens. b. Arouse the patient to confirm he still wants the medication. c. Give the medication as ordered and agreed to. d. Consult a colleague about what action to take.

ANS: C Feedback A The patient needs to receive the ordered pain medication now. B There is no reason to confirm the need for pain medication requested earlier. C Sleep is not synonymous with pain relief. When the patient reports a pain of 9 and asks for medication for which there is an order, he needs to receive the medication. D There is no reason to ask a colleague about giving the pain medication requested earlier.

Which body system does the nurse assess primarily by inspection? a. Respiratory b. Gastrointestinal c. Skin d. Cardiovascular

ANS: C Feedback A The respiratory system is assessed primarily using auscultation, but also percussion and inspection when observing pale or cyanotic skin from hypoxia. B The gastrointestinal system is assessed primarily by auscultation and palpation, but also with inspection when looking at the contour of the abdomen. C Skin is assessed primarily using inspection, but also palpation. D The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of perfusion or edema.

A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow rules when playing games. These are expected developmental achievements of a child of what age? a. 3 years old b. 4 years old c. 5 years old d. 6 years old

ANS: C Feedback A These are developmental behaviors too advanced for a 3-year-old child. B These are developmental behaviors too advanced for a 4-year-old child. C These are developmental behaviors consistent with a 5-year-old child. D These developmental behaviors are typically achieved and surpassed by a 6-yearold child.

A nurse is assessing the pain of an 86-year-old man who had hip surgery recently. The patient has been slightly confused since his surgery, but he responds to simple questions. What is the best way to assess this patient's pain? a. Ask him to rate his pain on a scale of 0 to 10. b. Ask him to rate his pain using a list of descriptive adjectives. c. Ask him to rate his pain using a vertical numeric scale. d. Observe his behavior and measure his vital signs.

ANS: C Feedback A This scale is appropriate for adolescents and adults, but older adults are assessed more accurately with a scale that they can see. B This method is not effective for assessing pain because adjectives have different meanings to different people. It is best to use a scale or pictures of faces. C Pain assessment in older adults is significantly improved by using a vertical numeric scale or pain faces. D Patient behavior and vital signs are not accurate ways to assess a patient's perception of pain.

The nurse notes in the patient's history that the patient has persistent, malignant pain. What is the meaning of this type of pain? a. The pain has been present for at least 2 weeks. b. The pain began after recent surgery and is associated with healing incisions. c. The pain has been present for 6 or more months. d. The pain has been present since surgery to remove cancer.

ANS: C Feedback A This time frame is too short. Chronic pain may be intermittent or continuous pain lasting more than 6 months. B This is a description of acute pain rather than chronic. C This is the definition of persistent or chronic pain. D Surgery to remove malignant tissue does not necessarily equate to malignant pain.

A nurse manager is reviewing interrelated concepts to professional nursing. Which concepts should the nurse manager consider when addressing concerns about the quality of health promotion? (Select all that apply.) a. Culture N b. Development c. Evidence d. Nutrition e. Health policy

ANS: C, E The interrelated concepts to professional nursing include evidence, healthcare economics, health policy, and patient education. Culture is a patient attribute concept. Development is a patient attribute concept. Nutrition is a health and illness concept.

Which technique should the nurse use to obtain more data about a patient's vague or ambiguous statement? a. Laughing and smiling during conversation b. Using phrases such as "Go on," and "Then?" c. Repeating what the patient has said, but using different words d. Asking the patient to explain a poin

ANS: D Asking the patient to explain a point is clarification, which is used to obtain more information about conflicting, vague, or ambiguous statements. Laughing and smiling during conversation may show attentiveness during the interview, but does not help to clarify vague information. Using phrases such as "Go on" and "Then?" encourages patients to continue talking, but does not help clarify. Rephrasing what the patient has said is restatement. It confirms your interpretation of what they said, but does not encourage additional talking.

A male patient tells the nurse that he rarely sleeps more than 4 hours a night and has not experienced any problems because of the lack of sleep. Which response by the nurse is most appropriate? a. "That is interesting." b. "Only 4 hours of sleep? How do you stay awake during the day?" c. "Really? Everyone needs more sleep than that." d. "Did I understand that you sleep 4 hours every night?"

ANS: D "Did I understand that you sleep 4 hours every night?" is a reflection technique that allows the nurse to confirm and obtain additional information. "That is interesting" does not provide an opportunity for the patient to explain any reason for the number of hours of sleep. "Only 4 hours of sleep? How do you stay awake during the day?" questions the accuracy of the patient's data and may not encourage the patient to give further details. "Really? Everyone needs more sleep than that" can be perceived as argumentative, but does not encourage further data from the patient.

8. The nurse documents which information in the patient's history? a. The patient's skin feels warm to the touch. b. The patient is scratching his arm. c. The patient's temperature is 100° F. d. The patient complains of itching.

ANS: D A patient's complaint of itching is subjective information, which means it is a symptom and is documented in the history. The patient's warm skin is objective information gathered by the nurse through palpation, is also a sign, and is documented in the physical examination. The patient's scratching is objective information gathered by the nurse through observation, is also a sign, and is documented in the physical examination. The patient's elevated temperature is objective information gathered by the nurse through measurement, is also a sign, and is documented in the physical examination.

For which person is an episodic or follow-up assessment indicated? a. The person who had abdominal surgery yesterday b. The person who is unaware of his high serum glucose levels c. The person who is being admitted to a long-term care facility d. The person who is beginning rehabilitation after a knee replacement

ANS: D An episodic or follow-up assessment is performed after the knee replacement to evaluate the outcome of the procedure. A shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A screening assessment is performed for the purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is performed during admission to a facility to obtain a detailed history and complete physical examination

11. Which activity illustrates the concept of primary prevention? a. Monthly breast self-examination b. Annual cervical (Papanicolaou test) examination c. Education about living with asthma d. Exercising three times a week

ANS: D Exercising is an example of primary prevention that prevents disease from developing by maintaining a healthy lifestyle. Monthly breast self-examination is an example of secondary prevention and screening efforts to promote early detection of disease. Annual cervical (Papanicolaou test) examination is an example of secondary prevention and screening efforts to promote early detection of disease. Teaching a patient how to live with a chronic disease such as asthma is an example of tertiary prevention directed toward minimizing the disability from chronic disease and helping the patient maximize his or her health.

A patient comes to the ambulatory surgery center for an elective procedure this morning. While giving the admission history, the patient states she is allergic to latex. What is the most appropriate response by the nurse at this time? a. Removing all latex products from the patient's room b. Using powdered gloves when providing care to this patient c. Informing the surgeon that the patient has type I hypersensitivity to latex d. Questioning the patient about symptoms experienced in the past with latex

ANS: D Questioning the patient about symptoms experienced in the past with latex is the appropriate response. When patients indicate an allergy to a medication or substance, ask them to describe what happens with exposure to determine whether the reaction is a side effect or an allergic reaction. Removing all latex products from the patient's room is unnecessary at this time because the latex allergy has not been confirmed. Using powdered gloves when providing care to this patient is unnecessary at this time because the latex allergy has not been confirmed. Informing the surgeon that the patient has type I hypersensitivity to latex is unnecessary at this time because the latex allergy has not been confirmed.

A patient comes to the emergency department and tells the triage nurse that he is "having a heart attack." What is the nurse's top priority at this time? a. Determine the patient's personal data and insurance coverage. b. Ask the patient to take a seat in the waiting room until his name is called. c. Request that a nurse collect data for a comprehensive history. d. Ask a nurse to start a focused assessment of this patient now.

ANS: D The nurse needs to begin an assessment as soon as possible that is focused on this patient's cardiovascular system. The type of health assessment performed by the nurse is also driven by patient need. Personal data and insurance information will be obtained, but in this situation, these data can wait until after the patient is assessed. Based also on Maslow's hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse needs to begin data collection, such as vital signs, immediately to determine the patient's health status. Complications can be prevented if an immediate assessment is made to analyze the patient's symptoms. A comprehensive history is not indicated in this situation at this time. Some subjective data will be collected, such as allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a priority at this time.

A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a "bad reaction" to the last tetanus immunization. What is the most appropriate response by the nurse in this case? a. Notify the health care provider that this immunization cannot be given. b. Document that the patient is allergic to the tetanus vaccine. c. Give the vaccine after explaining that adverse reactions are rare. d. Ask the patient to describe the "bad reaction" to the vaccine in more detail.

ANS: D The nurse needs to collect more data about the reaction from the patient to determine the type of reaction experienced. The nurse is trying to assess the relationship between the "reaction" reported by the patient and an allergic reaction. The immunization should not be eliminated at this time. Additional facts are needed to determine the type of reaction the patient experienced. Documenting an allergy to the tetanus vaccine may be an error because there are insufficient data to make that determination at this time. Giving the vaccine may be an error if the patient is allergic to the vaccine and additional data indicates that may be the case.

The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts sleep and has not been helped by over-the-counter cough medicines. Which question is most appropriate for the nurse to ask next? a. "So what do you think is causing this persistent cough?" b. "Have you tried taking sleeping pills to help you sleep?" c. "Did you think this will just go away on its own?" d. "What other symptoms have you noticed related to this cough?"

ANS: D "What other symptoms have you noticed related to this cough?" is part of a symptom analysis to provide more data. The answer to the question "So what do you think is causing this persistent cough?" is a guess by the patient and does not provide useful data. "Have you tried taking sleeping pills to help you sleep?" does not focus on the cough, which is what is disturbing the patient's sleep. "Did you think this will just go away on its own?" does not provide useful data and criticizes the patient's lack of action.

A patient reports "right shoulder pain that comes and goes" as the chief complaint. During the physical examination, the patient asks why the upper right abdomen is being examined for shoulder pain. What is the appropriate response from the nurse? a. "A comprehensive examination is required to determine the cause of your pain." b. "There may be associated problems that have not produced any symptoms yet that we want to identify." c. "Yes, this can be confusing, but if you will be patient I'm sure we can find something to help you." d. "It does seem odd, but the gallbladder doesn't have pain receptors of its own, so the pain shows up in the shoulder."

ANS: D Feedback A A focused examination is indicated at this time, not a comprehensive examination. B This patient's pain is due to referred pain, not to associated problems that have not produced any symptoms of pain. C This response reflects concern for the patient's pain, but does not address the patient's questions about examining the abdomen. D Referred pain is pain felt at a site different from that of an injured or diseased organ. It commonly occurs during visceral pain because many organs have no pain receptors; thus, when afferent nerves enter the spinal cord, they stimulate sensory nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located.

A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen? a. Flatness b. Dullness c. Resonance d. Tympany

ANS: D Feedback A Flatness is heard over bones and muscle. B Dullness is heard over the liver. C Resonance is heard over normal lung tissue. D Tympany is a loud, high-pitched sound heard over the abdomen.

When assessing the pain level of an older adult, a nurse considers which factor? a. Neural transmission of pain is increased as a part of the aging process. b. Older adult patients are not reliable in their descriptions of pain and how it affects them. c. Physiologic indicators of pain that are unique to older adults are tachycardia and hypotension. d. The older adult may believe that pain is a factor of aging and not worth mentioning. .

ANS: D Feedback A Neural transmission is the same for older and younger adults. B Becoming older does not diminish one's ability to describe pain. C The physiologic indicators are the same for older and younger adults. D Some older adults may perceive pain as an expected aspect of aging that they must endure

A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom? a. Abdominal pain b. Spinal deformity c. Back pain d. Breathing difficulty

ANS: D Feedback A Positions used by patients with abdominal pain vary depending upon what organ is involved. For example, patients with appendicitis tend to lie very still; those with acute pancreatitis prefer the fetal position for pain relief. B Spinal deformity usually affects the patient's gait or causes a slumped posture. C Back pain usually affects the patient's gait or causes a slumped posture. D Breathing difficulty is associated with the tripod position, which allows maximal expansion of the muscles of respiration

Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen saturation? a. The chest over the patient's heart b. Over the patient's abdominal aorta c. Over the patient's radial pulse d. Around the patient's index finger nail

ANS: D Feedback A The chest over the patient's heart is an incorrect option because the LED would not be able to reflect off oxygenated and deoxygenated hemoglobin molecules circulating in blood. B Over the patient's abdominal aorta is an incorrect option because the LED would not be able to reflect off oxygenated and deoxygenated hemoglobin molecules circulating in blood. C Over a patient's radial pulse is an incorrect option because the LED would not be able to reflect off oxygenated and deoxygenated hemoglobin molecules circulating in blood. D The sensor is taped to a highly vascular area, such as around the index finger nail that allows the light-emitting diode (LED) to reflect off oxygenated and deoxygenated hemoglobin molecules circulating in blood.

1. How do nurses assess a patient's pain? a. By assessing physiologic changes of the patient b. By understanding the sensory experience related to the amount of tissue damage c. By the patient's medical diagnosis or surgical procedure d. By asking the patient to rate the pain being experienced

ANS: D Feedback A The pain perceived is unrelated to the physiologic changes of the patient. B Although pain occurs when tissues are damaged, there is no correlation between the amount of tissue damage and the degree and intensity of pain experienced. C There is no correlation between pain perceived and a medical diagnosis or surgical procedure. D Pain is whatever the patient says it is. One person cannot judge the perception or meaning of pain of another person.

Nurses understand that a patient's diastolic pressure represents which physiologic function? a. The pressure needed to open the aortic and pulmonic valves b. The pressure in blood vessels when the ventricles contract c. The pressure of the blood returning to the heart from the venous system d. The pressure in blood vessels when the ventricles are relaxed

ANS: D Feedback A The pressure needed to open the aortic and pulmonic valves is called the afterload. B The pressure in blood vessels when the ventricles contract is the definition of the systolic pressure. C The pressure of the blood returning to the heart from the venous system is incorrect. D The pressure in blood vessels when the ventricles are relaxed is the definition of the diastolic pressure

After obtaining a history from the parents and inspecting the skin, the nurse determines which child needs further evaluation? a. The child who has a 1-cm red spot on the back of the neck, a fever of 100° F, and clear nasal drainage. b. The child who has a 2-cm slightly-raised, reddened area with a sharp demarcation line on the back of the neck. c. The child has a 2-cm abrasion on the right knee, a 3-cm abrasion on the left knee, and scrapes on both palms. d. The child who has several flat, bluish discolorations of the skin on the abdomen and back from 2 to 6 cm.

ANS: D Feedback A This child has a stork bite birthmark on the back of the neck and an upper respiratory allergy or viral infection. B This is a strawberry hemangioma, a birthmark that disappears by 5 years of age. C This child probably fell down while running, skinned both knees, and tried to break the fall with the hands. D Bruising in unusual areas (such as upper arms, back, buttocks, and abdomen) or multiple bruises found at different stages of healing should be further investigated to determine if there is abuse

An American Indian mother expresses concern about an irregularly shaped, dark area over her neonate's sacrum and buttocks. What is the nurse's most appropriate response to this mother? a. "This area will continue to grow until the infant is 10 to 15 months old." b. "This is a birth mark, which usually disappears by age 5 years." c. "This skin abnormality will require follow-up care." d. "This is a birth mark and they usually disappear by age 1 or 2 years."

ANS: D Feedback A This description refers to cavernous hemangioma that requires frequent reassessment. B This description refers to a "stork bite" (telangiectasis). C This is an inappropriate response. D This description refers to a Mongolian spot.

A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient? a. Asking him if the pain hurts "a little or a lot" b. Asking him to rate the pain on a scale of 0 to 10 c. Using the visual analog scale to rate the pain d. Using the Wong/Baker FACES rating scale

ANS: D Feedback A Using adjectives such as these is not reliable to assess pain in patients of any age. B This scale is appropriate for adolescents and adults, but a child cannot understand the concept of using numbers to rate pain. C This type of scale is appropriate for adults, but a child cannot understand the concept of using a straight line to rate pain. D This tool is appropriate for children who can point to the child's face that best represents how they are feeling.

How does the nurse perform the bimanual technique of palpation to assess organs? a. Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm b. Holding a light source in one hand while stroking the skin lightly with the dominant hand c. Using the ulnar surfaces of both hands to press inward 4 to 5 cm d. Using both hands, one anterior and one posterior, to entrap an organ between the fingertips

ANS: D Feedback A Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm describes light palpation, which is different from the bimanual technique. B Holding a light source in one hand while stroking the skin lightly with the dominant hand is used when inspecting rather than palpating. C Using the ulnar surfaces of both hands to press inward 4 to 5 cm describes an incorrect technique. D Using both hands, one anterior and one posterior, to entrap an organ between the fingertips is the correct technique for bimanual palpation.

The nurse is unable to assess an adult patient's pulse oximetry level due to patient wearing nail polish. What is an alternate site for the nurse to assess the patient's pulse oximetry level? a.The patient's mouth b.The patient's earlobe c.The patient's fingers d.None of the above

b. The toe, earlobe, and nose are alternative sites for a pulse ox reading

What is the purpose of Healthy People 2030? a.To make recommendations about prevention services using a five level grading system b.To provide health related recommendations to worldwide vulnerable populations c.To make as many grade A recommendations as possible to optimize the health of Americans d.To create an outline of national goals and objectives related to improving health

d. To create an outline of national goals and objectives related to improving health