Jarvis Health Assessment Adaptive Quizzing CH 1-11

Which distance between two individuals is considered the intimate zone? 1. 1 foot 2. 3 feet 3. 5 feet 4. 13 feet

1. 1 foot Rationale 0 to 1.5 feet indicates the intimate zone. The distance of 1.5 feet to 4 feet indicates personal distance. The nurse would not be talking to the patient from these distances. The social distance ranges from 4 to 12 feet. The nurse would always communicate with the patient at this distance range. The distance of 12 feet and above indicates public distance. p.25

While assessing a Hispanic child, the nurse finds that the child's parents use herbal remedies, perform prayers, and consult the health care provider only when the child is ill. Which approach will the nurse take to provide culturally competent care? 1. Acknowledging the parents' practices 2. Suggesting that the parents avoid using herbal remedies 3. Explaining the benefits of medications over herbal remedies 4. Suggesting that the parents give herbal remedies with food

1. Acknowledging the parents' practices Rationale While caring for individuals from different cultural groups, the nurse would be aware of the cultural practices and would acknowledge them. This helps the nurse provide culturally competent care. If the nurse suggests that the parents avoid using herbal remedies, then they may feel offended and may feel that the nurse does not respect their cultural beliefs. Explaining the benefits of medications over herbal remedies may not change cultural practices and beliefs. Herbal remedies are not clinically tested and may interact with food substances; this may result in adverse effects. Thus the nurse would not suggest giving the herbal remedies with food. p.8

A geriatric patient with severe fever and reddish discoloration of the tongue tells the nurse, "I'm sick because of imbalance in yin and yang .11 Which cultural group shares the same beliefs as this patient? 1. Asian 2. African 3. European 4. American Indian

1. Asian Rationale According to Chinese philosophy, imbalance between the yin and yang can impair bodily functioning and result in illness. Many people from Asian countries such as China, lndia,Japan, Korea, the Philippines, Laos, Cambodia, and Vietnam believe in this philosophy. Therefore Asian culture supports the patient's belief. Some individuals from African countries believe that disharmony with nature causes illness. In European countries, some individuals believe that absence of well-being or feeling bad results in illness. Some American Indians believe that disharmony with nature causes illness. Therefore African, European, and American Indian cultures do not support the patient's belief. p. 16

The patient tells the nurse, "I am the almighty and your creator. You all must do as I say; I am your ruler." Which thought content abnormality would the patient exhibit? 1. Delusions 2. Obsessions 3. Compulsions 4. Hypochondriasis

1. Delusions Rationale Delusions are a patient's irrational and fixed false beliefs. The patient with this abnormality may believe that he or she is the almighty, creator, ruler, God, or a god. Obsessions are unwanted, recurrent, and persistent thoughts or impulses that are intrusive and senseless. With obsessions the patients know the thoughts are not real, whereas patients with delusions truly believe the delusions are real. Compulsions are unwanted repetitive behaviors (not beliefs) that are performed to prevent discomfort or a dreaded situation. Excessive worrying about one's own health and feeling sick without any underlying physical problem indicate that the patient has hypochond riasis. p.82

Which part of the hand would the nurse use to assess the skin texture, swelling, and the presence of lumps during palpation? 1. Fingertips 2. Base of fingers 3. Fingers and thumb 4. The backs of the hands and fingers

1. Fingertips Rationale The fingertips are the best to palpate skin texture, fluid accumulation, and presence of an abnormal body mass because of the concentration of sensory nerve endings. The base of the fingers or ulnar surfaces of the hand are best for assessing vibrations of body cavities. A grasping action of the fingers and the thumb is best to determine the placement, spatial arrangement, and consistency of organs. The backs of the hands and fingers are best for determining body temperature, because of the presence of thin skin. p. 113

Which tools in the electronic and print format can be used to collect the family history? Select all that apply. 1. My Family Health Portrait 2. Personal health record 3. Electronic health record 4. Utah Health Family Tree 5. Activities of daily living records

1. My Family Health Portrait 4. Utah Health Family Tree Rationale My Family Health Portrait and the Utah Health Family Tree are official electronic tools to collect family history. Patients can log in to these tools and enter details about all their family members. Nurses can then use these tools to obtain the history and plan effective interventions. The personal health and electronic health record tools include an individual's health care data, but not information regarding the patient's family. Activities of daily living records are used to assess a person's self-care abilities but are not used to record family history. p.48

Which phase of nociceptive pain signifies the conscious awareness of a painful sensation? 1. Perception 2. Modulation 3. Transduction 4. Transmission

1. Perception Rationale Perception is the third phase of nociceptive pain, and it signifies the conscious awareness of a painful sensation in the patient. During this phase, the limbic system interprets the noxious stimuli and elicits emotional responses to pain in the patient. During the modulation phase, the body slowly reduces the pain by stopping the processing of a painful stimulus. During the transduction phase, the pain signals are transmitted from the site of injury to the spinal cord. During the transmission phase, the pain signals move from the spinal cord to the brain; they do not elicit emotional responses to pain. Test-Taking Tip: Look for answers that focus directly on the patient or the patienfs feelings rather than functions of the body. p. 161

Under which section of the health history would the nurse record pain severity? 1. Present health 2. Biographic data 3. Review of systems 4. Reason for seeking care

1. Present health Rationale The nurse is quantifying a symptom in the patient, so this information is recorded in the present health or history. Biographic data includes information related to the patient's occupation, ethnicity, and health practices. The review of systems does not include information regarding symptoms of the present illness. Reason for seeking care includes only the patient's spontaneous statements but not analysis of the symptoms. p.46

Which neurotransmitters are released at the site of injury? Select all that apply. 1. Glutamate 2. Histamine 3. Bradykinin 4. Prostaglandin 5. Gamma-aminobutyric acid

2. Histamine 3. Bradykinin 4. Prostaglandin Rationale Histamine, bradykinin, and prostaglandin are the neurotransmitters that are released at the site of injury. These neurotransmitters send the signal of pain to the spinal cord. Glutamate and gamma-aminobutyric acid are released from the brain and block the transmission of pain impulses. p. 161

Which distance would the nurse maintain from a patient while conducting an interview? 1. Intimate 2. Social distance 3. Public distance 4. Personal distance

2. Social distance Rationale The nurse would maintain social distance to interview the patient. Maintaining an intimate or personal distance during the interview may cause anxiety in the patient. Intimate distance should be maintained to assess the patient's breathing. Standing at a distance of more than 12 feet (public distance) during the interview may indicate that the nurse is not concerned about the patient. The nurse would maintain personal distance during the physical assessment of the patient. p.25

Which pieces of data are considered subjective? 1. Signs observed by the nurse 2. Symptoms reported by the patient 3. Findings obtained from x-ray reports 4. Results obtained from blood tests

2. Symptoms reported by the patient Rationale Subjective data are the information reported by the patient during the assessment. Subjective data include symptoms, the patient's perception of the illness, and so on. The data obtained by the nurse from diagnostic and laboratory tests are known as objective data. Therefore the signs observed by the nurse, x-ray reports, and blood tests are considered objective data. p.2

Which equipment is used to test the hearing capacity of a patient? 1. Otoscope 2. Tuning fork 3. Stethoscope 4. Monofilament

2. Tuning fork Rationale The nurse may use a tuning fork as part of the clinical assessment to test the auditory capacity and functioning of the patient. High-frequency vibrating tuning forks are placed over the bony prominences of the ear and directly on top of the scalp; an inability to hear the vibrations produced is indicative of hearing loss. An otoscope is used to view the internal structures of the ear and ear canal. A stethoscope is used to auscultate a variety of sounds generated in the body, such as heart sounds and breath sounds. A monofilament is used to assess sensation in the patient's foot and soles. p. 115

Which is a positive nonverbal behavior of an interviewer? 1. Bland expression 2. High-pitched tone 3. Equal-status seating 4. Slouching in the chair

3. Equal-status seating Rationale Equal-status seating is a type of sitting in which the nurse sits at the same level as the patient while facing him or her. This behavior indicates that the nurse is not assuming superiority, which encourages the patient to interact freely with the nurse. Speaking in a high-pitched tone may indicate to the patient that the nurse is being disrespectful. Therefore the nurse would speak slowly to the patient in a soft voice. Slouching in the chair may give an impression that the interviewer is not active and is not interested in learning about the patient. Similarly, having a bland expression also indicates that the nurse is not interested in the interview. p.32

Which is a component of the review of systems? 1. Symptom analysis 2. Immunizations 3. Health promotion 4. Prenatal status

3. Health promotion Rationale The review of systems includes a patient's past and present physical health status. The patient's health promotion is a component of the review of systems, because it helps to understand the patient's current health-promotion practices. The nurse will perform a symptom analysis after the assessment and review of systems. Immunizations and prenatal status constitute the past health history of the patient. p.50

Which condition would the nurse categorize as a third-level priority problem? 1. Impaired circulation 2. Acute pain 3. Impaired physical activity 4. Mental status change

3. Impaired physical activity Rationale Conditions that are not life-threatening and do not require immediate treatment are considered third-level priority problems. Impaired physical activity may cause obesity but does not lead to an immediate health crisis, so it is considered a third-level priority problem. Impaired circulation is considered a first-level priority problem because of the potential for infection and/or necrosis. Acute pain and change in mental status can impair the patient's daily activities. Therefore these conditions require immediate treatment and are considered second-level priority problems. p. 5

Which parts of the ophthalmoscope are present on the front of the ophthalmoscope head? Select all that apply. 1. Lens selector 2. Lens indicator 3. Mirror window 4. Viewing aperture 5. Aperture selector

3. Mirror window 5. Aperture selector Rationale The head of the ophthalmoscope consists of five different parts: viewing aperture, aperture selector, mirror window, lens selector, and lens indicator. The mirror window is present on the front, because it enables the examiner to look through the pupil at the background of the eye. The aperture selector is also present in the front end. It helps the examiner select the specific aperture to assess a specific part of the eye. The lens selector, lens indicator, and the viewing aperture are at the rear end of the ophthalmoscope head. The lens selector brings objects into focus while examining the eye. The lens indicator displays a number, which indicates the value of the lens, which may either be positive or negative. The viewing aperture has five different apertures to help the examiner assess for any vision problems. p. 116

Under which section in the review of body systems would the nurse document a history of back pain? 1. Endocrine system 2. Neurologic system 3. Musculoskeletal system 4. Peripheral vascular system

3. Musculoskeletal system Rationale The review of body systems records the past and present health status of each body system. In the musculoskeletal system, the problems associated with the muscles and the skeleton, such as muscle pain, cramps, gait problems, and back pain, are included. In the endocrine system, the symptoms and history of endocrine disorders such as diabetes and thyroid gland disorders are recorded. In the neurologic system, motor functions, cognitive functions, sensory functions, and mental status are included. In the peripheral vascular system, the symptoms associated with the obstruction of blood flow in the arteries and veins are included. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses. p.52

Which type of database is suitable for a short-term problem? 1. Emergency 2. Follow-up 3. Problem-centered 4. Complete

3. Problem-centered Rationale A problem-centered database is suitable for treating a short-term problem. The nurse would focus on a small, targeted scope concerning one problem, one cue complex, or one body system. An emergency database is suitable to provide treatment in emergency conditions, because it contains all crucial information required to initiate effective treatment. A follow-up database helps treat both short-term and chronic problems. It contains data on the conditions to be evaluated at frequent intervals. A complete database helps manage care for chronic disorders, because it contains the patient's complete health history. p. 6

The nurse is preparing to obtain the height of a 70-year-old male patient who is established at the practice, and the patient states, "I'm 5'10" tall and have been all my life, so you don't need to measure" Which response is appropriate? 1. "It is possible for older adults to become taller later in life" 2. "You seem concerned about our need to obtain your height." 3. "We need to have a baseline height for our medical records." 4. "As people age the vertebral disks thin, which decreases height."

4. "As people age the vertebral disks thin, which decreases height." Rationale As people age the vertebral disks become thinner, which leads to vertebral shortening. This, along with postural changes from kyphosis, can lead to a decrease in height. Older adults do not gain height. The patient may be concerned, but this is not the best response because it fails to provide information. The patient is an established patient, so the measurement is not a baseline height. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way. p. 135

Which describes orthostatic hypotension? 1. An abnormally low blood pressure (BP) 2. Disappearance of the Korotkoff sound during phase V 3. Higher blood pressure in the upper extremities than the lower ones 4. A decrease in blood pressure moving from supine to standing positions

4. A decrease in blood pressure moving from supine to standing positions Rationale Orthostatic hypotension can be defined as a drop in systolic pressure of more than 20 mm Hg or an increase in pulse of 20 beats per minute or more that occurs with a quick change to a standing position. It is caused by peripheral vasodilation without a compensatory increase in cardiac output. An abnormally low BP is called hypotension. A congenital form of narrowing of the aorta is called coarctation. During the measurement of blood pressure, disappearance of Korotkoff sounds during phase V gives the diastolic pressure. p. 150

Which thermometer can measure the oral temperature of a child within 25 seconds? 1. Glass thermometer 2. Temporal artery thermometer 3. Tympanic membrane thermometer 4. Electronic thermometer with blue-tipped probe

4. Electronic thermometer with blue-tipped probe Rationale The electronic thermometer with a blue-tipped probe measures oral temperature within 20 to 30 seconds. The glass thermometer measures oral temperature within 2 to 3 minutes, not within 25 seconds. The tympanic membrane thermometer records temperature by detecting infrared radiation from the tympanic membrane and, therefore, does not help measure oral temperature. The temporal artery thermometer detects infrared emissions from the temporal artery thereby recording the temperature; it does not detect oral temperature. p.140

Which type of abuse involves belittling and threatening? 1. Neglect 2. Sexual 3. Physical 4. Emotional

4. Emotional Rationale Belittling and threatening are examples of emotional abuse. Neglect includes lack of supervision and failure to provide the basic physical, emotional, and medical needs. Sexual abuse includes rape, sodomy, and penetration. Physical abuse includes biting, pushing, shaking, kicking, punching, and beating. Physical abuse may result in injuries. p.99

A child says, "My father always criticizes me because I have darker skin." Which type of abuse is the child experiencing? 1. Neglect 2. Sexual 3. Physical 4. Emotional

4. Emotional Rationale Belittling or downgrading a person is a form of emotional abuse. This kind of abuse can hinder the emotional development of the child and impair the development of self-esteem in the child. When the child is not provided with the basic requirements for a healthy life, the child is neglected. Sexual abuse involves fondling the genitals, sodomy, and penetration. Criticizing the child for the child's appearance does not indicate sexual abuse. Beating, punching, or hitting a child indicates physical abuse. p.99

Which finding from a mental status assessment is considered normal after a patient loses a job? 1. Feels worthless 2. Feels suicidal 3. Is delusional 4. Is tearful

4. Is tearful Rationale A normal mental status assessment finding after the loss of a job is being tearful. A loss of a job causes transient dysfunction, and this is an expected response. Feelings of worthlessness or suicide are abnormal. Delusional thinking is an abnormal mental status assessment finding when a patient loses a job. p. 63

Which information would the nurse educator include regarding the seating of the patient and the interviewer while teaching nursing students about interviewing techniques? 1. Stand in front of the patient. 2. Sit facing the patient across a desk. 3. Sit at a distance of 3 feet from the patient. 4. Maintain equal-status seating with the patient.

4. Maintain equal-status seating with the patient. Rationale During an interview, the patient and the interviewer should have equal-status seating. This allows them to be seated comfortably at eye level. Equal-status seating allows the patient to face the nurse or look straight ahead from time to time. Standing over the patient may indicate hurriedness or superiority, and should be avoided. Sitting across the desk creates a barrier and interferes with effective communication. Sitting at a distance of 3 feet may indicate encroaching on the personal space of the patient. The distance between the interviewer and the patient should be 4 to 5 feet. p.25

Which mental health disorder is characterized by intrusive thoughts and ritualistic behaviors? 1. Social anxiety disorder 2. Generalized anxiety disorder 3. Posttraumatic stress disorder 4. Obsessive-compulsive disorder

4. Obsessive-compulsive disorder Rationale Obsessive-compulsive disorder is characterized by intrusive thoughts and ritualistic behaviors. Obsessions are repetitive thoughts or impulses that can include the irrational fear of being infected through ordinary objects or daily interactions with people. Compulsions are repetitive behaviors that are performed in an attempt to control or decrease the discomfort caused by obsessions. Social anxiety disorder is characterized by severe anxiety and excessive self-consciousness in regular social situations. Generalized anxiety disorder is characterized by excessive worrying concerning future events. Posttraumatic stress disorder is caused by exposure to a traumatic event and is characterized by insomnia, hypervigilance, and lack of concentration. p. 79

Which phase of nociceptive pain involves the release of bradykinin and prostaglandins? 1. Perception 2. Modulation 3. Transmission 4. Transduction

4. Transduction Rationale During the transduction phase, bradykinin and prostaglandins are released from the injured tissues. These chemicals transmit pain signals from the injury site to the spinal cord. Perception is the third phase of nociception and is associated with conscious awareness of a painful sensation. The modulation phase is associated with alleviation of the pain stimulus, because there is no release of bradykinin and prostaglandins from injured tissues. During the transmission phase, endogenous opioids are released, which activate opioid receptors and block the transmission of pain impulses. p. 161

Which environmental factors cause acculturative stress? Select all that apply. 1. Legal status 2. Discrimination 3. Family conflict 4. Unemployment 5. Language barriers

4. Unemployment 5. Language barriers Rationale A patient who has recently immigrated to a country may have difficulty in adjusting to the new systems and beliefs of that country and people. This causes acculturative stress in the patient. Unemployment and language barriers are environmental factors that cause acculturative stress. Because of unemployment, the patient may have financial difficulties, resulting in stress. Because of language barriers, the patient may not be able to interact with people effectively. This makes the patient feel isolated, which causes stress. Legal status and discrimination are societal factors that cause acculturative stress. Family conflict is a social factor that ca uses acculturative stress. p. 14

Which substance is the most used and abused psychoactive drug in the United States? 1. Alcohol 2. Cocaine 3. Morphine 4. Heroin

1. Alcohol Rationale Alcohol is the most used and abused psychoactive drug. More than half (56%) of Americans ages 18 and older report being current alcohol drinkers. Cocaine, morphine, and heroin are not the most used and abused. The prevalence of Americans ages 12 or older reporting the use of any of the illicit drugs listed above (cocaine, morphine, and heroin) is 10.1%. Test-Taking Tip: Identifying the content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 85

Which observation is correct when assessing mobility of a patient who is walking across the room? 1. Gait 2. Posture 3. Symmetry 4. Position

1. Gait Rationale The nurse will ask the patient to walk across the room to assess his or her gait. A patient with a normal gait will have a smooth and even walk-cycle. To assess posture, the nurse would ask the patient to stand still and observe the normal "plumb line11 through the anterior ear, shoulder, hip, patella, and ankle. If the body parts of the patient look equal bilaterally, and are in relative proportion to each other, then the body parts are symmetrical. For this assessment, the patient is not required to walk across the room. To assess the correct body position of the patient, the nurse will ask the person to sit comfortably with the arms relaxed at sides and head turned toward the nurse. p. 126

Which associated disorders may be found in a patient with neuropathic pain? Select all that apply. 1. Herpes zoster 2. Liver metastasis 3. Postoperative pain 4. Trigeminal neuralgia 5. Distal polyneuropathy

1. Herpes zoster 4. Trigeminal neuralgia 5. Distal polyneuropathy Rationale Herpes zoster, trigeminal neuralgia, and distal polyneuropathy are the disorders that cause neuropathic pain because they cause a primary lesion, called a neuroma, and damage the nervous system. Liver metastasis is visceral damage that results in nociceptive pain. Postoperative pain is somatic damage that causes nociceptive pain. p. 172

Which physiologic changes result in hypertension? Select all that apply. 1. Increased blood volume 2. Decreased cardiac output 3. Decreased blood viscosity 4. Increased vasoconstriction 5. Increased elasticity of vessel walls

1. Increased blood volume 4. Increased vasoconstriction Rationale Blood pressure is affected by the changes in blood volume. An increase in blood volume increases central venous pressure, which ultimately increases the cardiac output and blood pressure. During vasoconstriction, more pressure is required to push the blood contents; therefore it increases the blood pressure in the patient. Increased (rather than decreased) cardiac output leads to an increase in blood pressure. Viscosity and pressure are in direct proportion. Therefore as the viscosity of blood increases, more pressure is required to pump the blood, leading to increased blood pressure. The increased elasticity of blood vessel walls translates to less pressure to push the contents; therefore the blood pressure decreases. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 145

Arrange the assessments performed by the nurse in a sequential order during the routine physical examination of a patient. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

1. Inspection 2. Palpation 3. Percussion 4. Auscultation Rationale For most examinations, except for abdominal examinations, the steps of physical assessment are performed in a sequence from least intrusive to most intrusive: inspection, palpation, percussion, and auscultation. While doing a routine physical assessment of a patient, the nurse would first perform inspection, which refers to the general observation of the patient to detect the presence of any abnormality. Palpation refers to the assessment of the alignment, intactness, warmth, and tenderness of an organ using hands or fingertips. Percussion is the technique in which the patient's body part is struck to assess the density of the underlying organs. Auscultation is the act of listening to voluntary and involuntary sounds produced by body cavities, such as heart sounds and lung sounds. In an abdominal examination auscultation is performed before percussion and palpation.

Nursing care plans are written accurately and kept up-to-date. Which rationale supports the practice of writing accurate nursing care plans and keeping them up-to-date? Select all that apply. 1. Is useful for conducting research 2. Assists with insurance reimbursement 3. Helps evaluate the patient's response to treatment 4. Aids in establishing a therapeutic relationship with the patient 5. Is essential for providing culturally competent care for the patient

1. Is useful for conducting research 2. Assists with insurance reimbursement 3. Helps evaluate the patient's response to treatment Rationale It helps the nurse conduct research and find new interventions to provide effective care for the patient. Because the care plan contains treatment provided for the patient, it can be used for insurance reimbursement and to evaluate the effectiveness of the treatment. Thus the nurse would document the data in the care plan accurately and would keep it up-to-date. The care plan does not help establish a therapeutic relationship or provide culturally competent care for the patient. Therefore to establish a therapeutic relationship, the nurse would follow therapeutic communication methods. The nurse would consider the patient's cultural beliefs and practices to provide culturally competent care. p. 5

The nurse is measuring a patient's thigh blood pressure (BP). Which is the most important point that the nurse should remember about thigh pressure? 1. It is higher than in the arm. 2. It should be measured only in infants. 3. It can be measured only in the prone position. 4. The pulse pressure is greater in the thigh than in the arm.

1. It is higher than in the arm. Rationale Normally, thigh BP is higher than that of the arm. If thigh pressure is lower than the arm pressure, it indicates coarctation of the aorta. Thigh pressure should ideally be measured in adolescents or young adults. Though thigh pressure is preferably measured in a prone position, it can also be measured in the supine position. The knee needs to be bent while measuring thigh pressure in the supine position. Normally, the systolic value is 10 to 40 mm Hg higher in the thigh than in the arm, as is the diastolic pressure, but the pulse pressure does not necessarily change. p.150

Which parameter is the nurse assessing when the patient is asked about the date and time? 1. Orientation 2. Thought process 3. Thought content 4. Remote memory

1. Orientation Rationale The questions about time and date are asked to find out whether the patient is oriented or not. To assess the thought process of a person, the nurse would ask the person to speak about a specific topic and determine whether the patient can complete a thought. Thought content can be observed by making sure the content is consistent and logical. Remote memory can be assessed by asking the patient about verifiable past experiences. pp. 66-67

The aging patient with dementia appears agitated and is pacing and yelling. Which would the nurse infer as the cause of the agitation? 1. Pain 2. Worsening dementia 3. Medication overdose 4. Decreased prostaglandin levels

1. Pain Rationale When a patient with dementia experiences pain, he or she may exhibit agitation, pacing, and repetitive yelling. These findings do not indicate an exaggeration of dementia in the patient. Medication overdose may not cause agitation, pacing, and repetitive yelling, but causes other systemic symptoms. The pain worsens because of increased prostaglandin levels, not decreased prostaglandin levels. P. 169

Which information will the nurse learn about a patient using the Brief RCOPE assessment tool? 1. Religious coping 2. Intensity of pain 3. Psychological symptoms 4. Cognitive development

1. Religious coping Rationale Brief RCOPE is an assessment tool that contains 14 questions about the patient's belief in and perception of God. This helps the nurse identify religious coping in the patient and prevent negative health outcomes resulting from negative religious coping. A patient's religious coping can play a major role in determining the effectiveness of the treatment. Some patients may believe that illness is caused by God's punishment or an act of the devil. Such beliefs may affect the patient's coping skills and may hinder treatment effectiveness. Brief RCOPE does not contain questions related to pain intensity. Therefore the nurse cannot assess the intensity of pain in the patient by using this tool. Brief RCOPE does not contain questions related to psychological symptoms and cognition. Therefore the nurse does not identify psychological symptoms or cognitive development in the patient by using Brief RCOPE. p. 20

Which nursing action would require written consent from an alert, adult patient who was abused by a partner? 1. Taking a digital photograph 2. Documenting statements made by the patient 3. Reporting previous abuses to the primary provider 4. Using partial direct quotations when charting

1. Taking a digital photograph Rationale Prior written consent to take digital photographs should be obtained from all cognitively intact, competent adults. Documentation of statements given by the patient and previous history of assaults do not require written consent because they are part of obtaining an accurate history and relaying pertinent information to other health care team members. Other aspects of the abuse history, including reports of past abusive incidents, can be paraphrased with the use of partial direct quotations. Written consent is not needed for this type of documentation. p. 101

Which statement made by the student nurse about the "evaluation" phase of the nursing process indicates effective learning? 1. "It is the -final phase of the nursing process and ends the plan of care." 2. "It is done to determine whether outcome goals have been met." 3. "It can be done only as a result of independent nursing interventions." 4. "It means that all the nursing interventions have been accomplished."

2. "It is done to determine whether outcome goals have been met." Rationale The nurse evaluates the efficacy of the nursing interventions in meeting the patient's outcomes in the evaluation phase. This is accomplished by comparing the outcome criteria with the patient's actions and behaviors. The evaluation phase does not end the plan of care. If the outcomes have not been met, the nurse needs to reassess the patient, plan new outcomes, plan and implement the new interventions, and evaluate the outcome once again. The evaluation phase helps assess the efficacy of the entire care plan and not just individual nursing interventions. The nurse will plan new patient outcomes if all goals are not met in the evaluation phase. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as more or speciflcally in the statement. p. 3

Which distance would the nurse maintain from the patient when assessing posture? 1. 1 foot 2. 2 feet 3. 5 feet 4. 7 feet

2. 2 feet Rationale The nurse is assessing the patient's posture. In this case the nurse would maintain a personal distance, which is about 1.5 to 4 feet. The nurse needs to maintain a distance of 1 foot while assessing the breath and body odors of the patient. The distance of 4 to 12 feet indicates social distance. The nurse maintains social distance while interviewing the patient. Therefore the nurse would not maintain a distance of 5 to 7 feet while performing the physical assessment. p. 25

Which respiratory rate is normal for a 9-year-old patient? 1. 16 breaths per minute 2. 22 breaths per minute 3. 28 breaths per minute 4. 32 breaths per minute

2. 22 breaths per minute Rationale The normal respiratory rate in a 9-year-old child is 18 to 24 breaths per minute, so a respiratory rate of 22 breaths per minute is a normal reading. The respiratory rate of 16 breaths per minute indicates bradypnea, which is slow breathing. The respiratory rates of 28 and 32 breaths per minute indicate rapid breathing, which is called tachypnea. p. 144

Which patient characteristics comprise "culture"? 1. Color of skin and hair 2. A system of beliefs and practices 3. Preference for education and studying 4. Physical features such as eye shape

2. A system of beliefs and practices Rationale Culture refers to a system of beliefs and practices that are learned and shared by a group of people. Color of skin and hair are genetically determined and not learned. A patient's preference for education and studying helps in understanding the social influences on the patient. A physical feature such as the shape of the eye has a genetic basis. p. 11

Which medical condition is a major cause of liver cirrhosis? 1. Tuberculosis 2. Alcohol abuse 3. Cardiomyopathy 4. Illicit drug use

2. Alcohol abuse Rationale Alcoholism is a major cause of liver cirrhosis. Although tuberculosis is associated with heavy drinking, it is not a major cause of liver cirrhosis. Although heavy daily drinking (>5 drinks per day) increases the risk of cardiomyopathy and heart failure, cardiomyopathy does not cause liver cirrhosis. Illicit drug use does not cause liver cirrhosis, but may affect the cardiovascular system, respiratory system, and brain. p.85

Which conditions are associated with visceral pain? Select all that apply. 1. Arthritis 2. Appendicitis 3. Fibromyalgia 4. Cholecystitis 5. Kidney stones

2. Appendicitis 4. Cholecystitis Rationale Visceral pain results from the activation of nociceptors of the visceral organs. Pain associated with appendicitis and cholecystitis is visceral pain. Chronic nonmalignant pain is often associated with musculoskeletal conditions such as arthritis and fibromyalgia. Pain caused by kidney stones is an example of acute pain. p. 162

Which illicit drug is most commonly used in the United States? 1. Meperidine 2. Cannabis 3. Methamphetamine 4. Cocaine

2. Cannabis Rationale Cannabis (marijuana) use is the most common, used by almost 80% of drug users. Meperidine is a pain medication that is used but not as often as marijuana. Methamphetamine is a category of illicit drug use but is not used as often as cannabis. Although cocaine is a category of illicit drug use, its use is not as common as that of marijuana. pp.86, 96

Which is an appropriate step to take before assessing a patient's blood pressure? 1. Remove the bladder balloon from the wrap . 2. Check that the patient's feet are fiat on the floor. 3. Protect the patient's skin from the cuff with cloth. 4. Check that the arm of the patient is above heart level.

2. Check that the patient's feet are fiat on the floor. Rationale For the most accurate blood pressure reading, the patient's feet must be fiat on the floor. Crossed legs artificially elevate the blood pressure. The bladder balloon should not be removed from the wrap because it gives a false high blood pressure reading. The patient's arm should be at heart level, not above it. The patient's skin must be bare to obtain the most accurate reading; therefore the nurse does not protect the patient's skin from the cuff with cloth. p. 147

Which interventions will the nurse do to obtain objective data? Select all that apply. 1. Speak to the patient's family. 2. Conduct a physical examination. 3. Review the laboratory reports. 4. Summon previous medical records. 5. Interview the patient.

2. Conduct a physical examination. 3. Review the laboratory reports. 4. Summon previous medical records. Rationale Objective data refers to the information gathered by inspection, percussion, palpation, and auscultation during the physical examination. The nurse also reviews the patient's laboratory reports for abnormalities while gathering objective data. The nurse reviews previous medical records to gather objective data. Subjective data is obtained by speaking to members of the patient's family. The patient also provides subjective data during an interview with the nurse. p.2

Which mental health disorder causes a gradual deterioration in the patient's cognitive functioning? 1. Delirium 2. Dementia 3. Depression 4. Anxiety

2. Dementia Rationale Dementia is a mental health disorder commonly seen in older adult patients; it is characterized by gradual cognitive impairment and progressively leads to the loss of memory and other cognitive functions. Delirium is an acute confusional state characterized by disorientation and disordered thinking and perceptions. Delirium has a sudden onset. Delirium is usually preceded by an acute illness such as an infection or drug intoxication. Depression is the state of dejection or sadness that may result in decreased motivation and hopelessness; it is not characterized by a deterioration in cognitive function. A patient with anxiety has symptoms of fear and worry concerning anticipated events and is not associated with a gradual deterioration of cognitive functioning. p. 80

Which characteristic would the nurse expect to find in a patient with anorexia nervosa? 1. Uses food for comfort 2. Has low body mass index 3. Eats to relieve stress 4. Intensely fears losing weight

2. Has low body mass index Rationale Patients with anorexia nervosa present with a low body mass index or severely low body weight for height. Patients with binge eating disorder use excessive food for comfort or to relieve stress. Patients with anorexia nervosa usually eat very little food or binge and then purge food by vomiting. Patients with anorexia nervosa have an intense fear of weight gain, not an intense fear of weight loss. pp.82-83

Which symptoms are expected in a patient suffering from an acute myocardial infarction? Select all that apply. 1. Depression 2. Hypotension 3. Hypohidrosis 4. Cool, clammy skin 5. Shoulder and jaw pain

2. Hypotension 4. Cool, clammy skin 5. Shoulder and jaw pain Rationale An acute myocardial infarction causes decreased cardiac output in the patient, leading to hypotension. In patients with acute myocardial infarction, the superficial blood vessels constrict to shunt blood to the vital organs; therefore the patient has cool and clammy skin. The patient with acute myocardial infarction may develop shoulder and jaw pain because the afferent sympathetic fibers enter the spinal cord from levels C3 to T4, accounting for a variety of locations and radiation patterns of chest pain; discomfort may radiate to the neck, lower jaw, left arm, and left shoulder, or occasionally to the back or down the right arm. The patient with acute myocardial infarction may have confusion, but not depression. Hypohidrosis is decreased sweating due to impaired sweat glands. The patient with acute myocardial infarction may have profuse sweating or diaphoresis, but not hypohidrosis.

Which finding would be seen in a patient with aphasia? 1 Cannot smell any fragrances, odors, or aromas 2. Inability to comprehend or express verbal language 3. Inappropriate attention span and impulsiveness 4. Unable to perform a purposeful act on command

2. Inability to comprehend or express verbal language Rationale Aphasia is a speech disorder in which the patient has difficulty understanding or producing language. The aphasic patient's olfactory senses are not impaired. Inappropriate attention span and impulsiveness are seen in a patient with attention-deficit/hyperactivity disorder, not aphasia. The patient's language comprehension ability is impaired, but the patient will be able to perform a purposeful act. Aphasia does not affect purposeful movement. p. 77

Which examples are categories of illicit drug use? Select all that apply. 1. Anti hypertensives 2. Inhalants 3. Beta-blockers 4. Hallucinogens 5. Marijuana

2. Inhalants 4. Hallucinogens 5. Marijuana Rationale Three of the 7 categories of illicit drug use include: inhalants, hallucinogens, and marijuana. Anti hypertensives and beta-blockers are cardiovascular drugs that are not examples of illicit drug use. p.86

Which function(s) do the nursing diagnoses in a plan of care serve? Select all that apply. 1. Guarantee financial reimbursement 2. Organize the appropriate assessment data 3. Serve as a focus for nursing documentation 4. Provide a basis for developing a care plan 5. Improve the clinical judgment of the nurse

2. Organize the appropriate assessment data 3. Serve as a focus for nursing documentation 4. Provide a basis for developing a care plan Rationale Nursing diagnoses serve to organize a great deal of patient data into a single statement. The nursing diagnoses also serve as a focus for nursing documentation. The nursing diagnoses help understand the patient's health concerns. Therefore the nurse can develop effective care plans for the patient. Insurance programs, not nursing diagnoses, ensure financial reimbursement. The nurse improves clinical judgment by research, not by formulating nursing diagnoses. p.2

Which type of abuse would the child have experienced when the nurse discovers burns and belt marks on the back? 1. Sexual 2. Physical 3. Neglect 4. Emotional

2. Physical Rationale A child who is physically abused has unusual injuries such as burns or belt marks on the back. Sexual abuse includes incest, penetration, rape, and sodomy. Neglect involves the parents' failure to provide for the basic needs of the child. This may cause malnutrition, which results in the susceptibility of the child to infections. Physical neglect does not involve directly harming the child. Emotional abuse involves belittling, rejection, and withholding of love and support. p.99

Under which section would the nurse record information about hearing aid use? 1. Present health 2. Review of systems 3. Biographic data 4. Functional assessment

2. Review of systems Rationale Health-promotion devices such as hearing aids and mobility aids are recorded under the review of systems section. The hearing aid is recorded as a health-promotion tip under the review of ears section. Present health includes the current health status of the patient. Biographic data include general information regarding the patient such as occupation, ethnicity, and health practices. Functional assessment deals with the patient's daily Iiving activities. p.51

Which finding indicates a normal value for the breath alcohol analysis test? 1. 0.08 2. 0.10 3. 0.00 4. 0.12

3. 0.0 Rationale: Normal value for the breath alcohol analysis test is 0.00. A level of 0.08 is legal intoxication in most states. Levels of 0.10 and 0.12 indicate elevated levels of alcohol in the blood. p. 93

How many hours of sleep are recommended for teenagers? 1. 5 2. 7 3. 9 4. 12

3. 9 Rationale Teenagers need about 9 hours of sleep per night. Teenagers in the United States report getting less than 6.5 to 7.7 hours of sleep per night. Getting only 5 and 7 hours is not enough, and 12 hours is oversleeping. p. 59

Under which section in the health history will the nurse include the patient's name and primary language? 1. Past history 2. Family history 3. Biographic data 4. Functional assessment

3. Biographic data Rationale While recording the patient's complete health history, the nurse will record the patient's personal details such as occupation, ethnicity, and health practices under the biographic data section. The patient's name and the languages the patient knows are personal details and therefore are recorded under biographic data. The information related to past illness will be included under the past history section. The family history section will contain all of the information related to family members. Functional assessment includes the patient's daily activities. p.45

Which is the best way for the nurse to determine the religious affiliation of a patient? 1. By physical characteristics 2. By surname 3. By cultural assessment 4. By health issues

3. By cultural assessment Rationale A cultural assessment includes an assessment of the patient's beliefs regarding nature, the universe, and spirituality, which helps in understanding the patient's religious affiliation. Physical characteristics will help in identifying the patient's race. A surname may help in denning the religion to which the patient comes from or was born into, but not necessarily the patient's current affiliation. Religious affiliation of a patient is based on the patient's beliefs and not on the patient's susceptibilities to illnesses. p. II

Which activity is the primary focus of the nursing process? 1. Determining and treating any potential physical or biological defects 2. Guiding patients through the process of receiving medical care 3. Diagnosing patient responses to actual or potential health problems 4. Applying theoretical frameworks to determine the patient's problems

3. Diagnosing patient responses to actual or potential health problems Rationale The primary focus of the nursing process is to diagnose patient responses to actual and potential health problems. This helps in planning effective interventions for the patient. The primary health care provider determines and treats potential physical and biological defects by prescribing appropriate treatments and therapies. The nurse does not guide the patients in medical treatment but does help ensure that the patients comply with the prescribed treatment. It is the responsibility of the primary health care provider to guide the patients. Applying theoretical frameworks helps organize assessment data, but this is not a main focus of the nursing process. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p.3

Which nursing intervention will help the nurse accurately measure respiratory rate in an obese patient? 1. Use 10-second intervals for measurement. 2. Inform the patient before starting the measurement . 3. Feel the breaths by placing a hand on the patient's abdomen. 4. Instruct the patient to take deep breaths throughout the assessment.

3. Feel the breaths by placing a hand on the patient's abdomen. Rationale The nurse would measure respiration in an obese patient by placing a hand on the upper chest or the abdomen to feel the breaths, as observation alone may be insufficient. The nurse would use 30-second intervals to measure the respiratory rate to prevent +4 to -4 deviation in the results; a 10-second interval is too short to be accurate. The nurse would not inform the patient before assessing breathing, because a sudden awareness of breathing may alter the normal pattern and may give a false measurement. The nurse would measure the normal breathing pattern of a patient, but would not instruct the patient to breathe deeply while assessing him or her. p. 143

While documenting a complete health history, under which section would the nurse record a patient's activities of daily living? 1. Family History 2. Review of Systems 3. Functional Assessment 4. Reason for seeking care

3. Functional Assesment Rationale Functional assessment is a person's ability to perform daily activities such as housekeeping, shopping, cooking, bathing, dressing, toileting, eating, and walking. Information regarding a patient's family members is recorded under the family history. Review of systems includes the health status of each system present in the body. Under the reason for seeking care section, the nurse records the patient's symptoms and the purpose of the visit. p.52

Which examination visualizes neurochemical changes in the brain caused by nociception? 1. X-ray examination (x-ray film) 2. Computerized axial tomography (CAT) scan 3. Functional magnetic resonance imaging (fMRI) 4. Traditional magnetic resonance imaging (MRI)

3. Functional magnetic resonance imaging (fMRI) Rationale Functional magnetic resonance imaging (fMRI) determines the structural, functional, and neurochemical changes caused in the brain by nociception. The x-ray examination, computerized axial tomography (CAT) scan, or traditional magnetic resonance imaging (MRI) cannot help in determining the neurochemical changes in the brain that lead to pain perception. p. 162

Which cultural practice is common among Turkish people? 1. Wearing metal bangles 2. Tying a seed to the newborn's crib 3. Hanging a glass blue eye in the home 4. Placing a packet in the newborn's crib

3. Hanging a glass blue eye in the home Rationale Many Turkish people may believe in evil spirits, so they hang a glass blue eye in their homes to ward off evil spirits. Unlike Mexicans, Turkish people do not traditionally tie a seed to the newborn's crib with a red string. Caribbean people, rather than Turkish people, are known for wearing metal bangles. Unlike Japanese people, Turkish people do not traditionally place a packet in the newborn's crib. p. 18

Which statement is true regarding acculturation? 1. There is a lack of a definitive cultural background. 2 There is a belief that one culture is superior . 3. Individuals adopt the culture of the majority. 4. There are structured patterns of behavior within a group.

3. Individuals adopt the culture of the majority. Rationale Acculturation occurs when an individual who is new to a country adopts the culture of the majority. Every person belongs to a cultural group and demonstrates the values and beliefs of that culture. Therefore acculturation does not refer to a lack of a cultural background. Ethnocentrism refers to the belief that one culture is superior to another. Assimilation, not acculturation, is the process of merging with a new culture. Culture, not acculturation, refers to the structured patterns of behavior within a group. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal. p. 14

Opioids inhibit which part of nociception? 1. Secretion of glutamate and adenosine triphosphate at the synaptic cleft 2 Secretion of histamine, bradykinin, and prostaglandins at the site of injury 3. Movement of the pain impulse across the synaptic cleft to the dorsal horn neurons 4. Movement of the pain impulses from the spinal cord to the thalamus via the ascending fibers

3. Movement of the pain impulse across the synaptic cleft to the dorsal horn neurons Rationale Opioid analgesics activate the opioid receptors located in the spinal cord and block the transmission of the pain impulses from the spinal cord to the thalamus; this occurs in the second phase of nociception. The secretion of histamine, bradykinin, prostaglandin, glutamate, and adenosine triphosphate (ATP) takes place during the first phase of nociception. The opioid analgesics do not inhibit the events of the first phase, because they do not block the receptors that secrete histamine, bradykinin, prostaglandin, and glutamate. The transmission of the pain impulses across the synaptic cleft to the dorsal horn neurons takes place because of the secretion of glutamate and ATP. Because the opioid analgesics do not inhibit the secretion of glutamate, they do not hinder the transmission of the impulses across the synaptic cleft to the dorsal horn neurons. p. 161

The child has been frequently hospitalized with either an injury or an infection and is currently showing signs of malnutrition. Which type of abuse would the nurse report that the patient is experiencing? 1. Physical 2. Sexual 3. Neglect 4. Emotional

3. Neglect Rationale A child who is neglected by caregivers may have malnutrition and is prone to frequent injuries and infection resulting from a lack of medical care. Parents who neglect their child fail to provide their child the basic needs, including physical, educational, medical, and emotional. Physical abuse involves physical injury caused by punching, beating, kicking, biting, burning, or shaking. Sexual abuse includes fondling a child's genitals, incest, penetration, rape, sodomy, and human trafficking. A child who is emotionally abused is usually withdrawn as a result of impaired emotional development but may not have any physical injury or infection. p. 99

Which kind of injury is caused by friction? 1. Cut 2. Bruise 3. Rug burn 4. Laceration

3. Rug burn Rationale The injuries that occur because of friction are known as rug burns. A rug burn is characterized by a scraped area of skin. A cut is caused by a sharp object. A bruise is the reddening and purpling of the skin that may occur because of the impact of a blow. A laceration is a wound that occurs because of splitting or tearing of the skin surface caused by blunt force trauma. p. 106

Which is the primary purpose of interviewing a patient? 1. To allow the patient to become acquainted with the nurse 2. To teach preventive health care methods to the patient 3. To get the patient's health history and current health status 4. To correlate the patient's complaints with objective signs

3. To get the patient's health history and current health status Rationale The primary purpose of interviewing a patient is to obtain the patient's health history. This helps in understanding the patient's health status and the patient's perception of his or her current health. This helps the nurse plan effective interventions. The focus of the interview is not to establish a rapport with the patient. The main focus is to understand the patient's problem. The nurse develops a teaching plan after determining the patient's health care needs. The nurse formulates a nursing diagnosis by correlating the patient's complaints with the objective signs after the interview. Test-Taking Tip: Key words or phrases in the question stem such as primary, early, or best are important. Similarly, words such as only, always, never, and all in the distracters are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. p.23

Which measure would the nurse take while collecting a history from an abused 7-year-old with a hand injury? 1. Ask long questions. 2. Use scientific terms . 3. Use simple language. 4. Ask closed questions.

3. Use simple language. Rationale Using simple, age-appropriate language can help enrich the history taking from a child. The nurse would obtain the history directly from the child because a 7-year-old can communicate verbally. The questions would be short so that the child understands the questions easily. The child cannot understand scientific terms. Therefore the nurse would avoid using medical jargon. Closed questions require a "yes" or "no" response, and open-ended questions require answering in the form of a sentence or paragraph. Therefore open-ended questions (not closed) help obtain a detailed history from the child. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details such as the patient's age in the question. p. 105

The nurse teaches the nursing student about recording immunizations. Which statement by the nursing student indicates effective learning? 1. "I will collect immunization information only for pediatric patients.11 2. "I will avoid recommending vaccines against the patient's preference." 3. "I will record only those immunizations that are related to the chief complaint." 4. "I will record dates of tetanus and flu shots when working with an adult patient."

4. "I will record dates of tetanus and flu shots when working with an adult patient." Rationale Adult patients would receive an influenza vaccine annually and a tetanus-diphtheria-pertussis vaccine once, with a booster every 10 years. Therefore the nurse would record the dates of these vaccines to evaluate whether the vaccination is up-to-date. It is important to collect vaccination information for both pediatric and adult patients, because there are different vaccine recommendations for different age groups. The nurse would urge all patients to obtain recommended vaccinations, because these are preventive measures against various diseases. The nurse would record all immunizations that the patient has received, not just those related to the chief complaint, to gauge the need for further vaccination. p. 47

Which question would the nurse ask the patient with rheumatoid arthritis to evaluate the effectiveness of corticosteroid therapy? 1. "When did your pain start?" 2. "What does this pain mean to you ?11 3. "Why do you think you are having pain?" 4. "What makes your pain better or worse?"

4. "What makes your pain better or worse?" Rationale To identify the effectiveness of the treatment, the nurse would ask the patient what makes the pain better or worse. It helps the nurse determine whether the treatment provided to the patient is effective in alleviating pain. The nurse asks the patient when the pain started to identify the onset and duration of the pain, but this does not help evaluate the effectiveness of the treatment. Asking questions like what pain means to the patient and what the patient thinks to be the cause of pain helps the nurse identify the pain myths and misconceptions the patient may believe. p. 164

Which type of substance use would the nurse assess for in a patient who presents with anxiety, dry mouth, and increased appetite, particularly for "junk" food? 1. Alcohol 2. Cocaine 3. Nicotine 4. Cannabis

4. Cannabis Rationale The use of cannabis, or marijuana, produces anxiety, dry mouth, and increased appetite, especially for "junk" food. Alcohol use produces sedation, depression, and unsteady gait. Cocaine use causes euphoria and nausea and vomiting, leading to loss of appetite and weight loss. Nicotine use causes jittery feelings and loss of appetite. p.96

Which screening tool would the nurse use to assess homicide risk? 1. Woman Abuse Screen Tool 2. Hurt, Insult, Threaten, Scream 3. Slapped, Threatened, and Throw 4. Danger Assessment

4. Danger Assessment Rationale The Danger Assessment tool assesses for homicide risk by asking a series of yes/no items. The Woman Abuse Screen Tool; the Hurt, Insult, Threaten, Scream tool; and the Slapped, Threatened, and Throw tool all assess for intimate partner violence, not homicide risk. p. 110

Which organ is considered the thermostat of the human body? 1. Skin 2. Pituitary 3. Brainstem 4. Hypothalamus

4. Hypothalamus Rationale The human body maintains thermostatic equilibrium by a feedback mechanism, regulated in the hypothalamus of the brain. Therefore the hypothalamus can be considered to be the thermostat of the human body. The pituitary is an endocrine gland that is located at the bottom of the hypothalamus. The primary function of the pituitary gland is hormone secretion. The pituitary gland does not help in thermo regulation. The brainstem is the posterior part of the brain that regulates heartbeat, breathing, and sleeping. The skin is the sentry that guards the body from environmental stresses such as trauma, pathogens, and dirt and adapts it to other environmental influences. p. 139

A patient with a viral upper respiratory infection says, "I've been drinking ginger tea for three days, but I've still got this cold.11 In which section will the nurse record this information? 1. Review of systems 2. Functional assessment 3. History of present illness 4. Medication reconciliation

4. Medication reconciliation Rationale While recording a patient's health history, the nurse records the previous medication history under the medical reconciliation section. This section also includes information about the over-the-counter medications and herbal remedies that the patient has used for relief. Drinking a cup of ginger tea is an herbal remedy to get relief from the cold and would be recorded under the medication reconciliation section. Under the review of systems section, the nurse records the health status of each body system. Under the functional assessment section, the nurse records the patient's daily activities. The patient's present health status is included under the history of present illness section. p.48

Which type of drinker would describe a male who consumes two drinks a day? 1. Heavy 2. Binge 3. Chronic 4. Moderate

4. Moderate Rationale The male patient who consumes two or fewer drinks per day is a moderate drinker. A patient who consumes greater than five drinks per day is referred to as a heavy drinker. A binge drinker consumes five or more drinks per occasion. The patient who consumes four or more drinks per day for 4 to 8 weeks is a chronic drinker. p.85

Which is characteristic of C fibers? 1. A large diameter 2. Presence of a myelin sheath 3. Rapid transmission of pain signals 4. Presence of diffused sensations

4. Presence of diffused sensations Rationale C fibers are unmyelinated sensory fibers that cause pain signals to be more diffuse. The C primary sensory fibers produce a diffused and aching sensation. Because of the absence of Schwann cells, these fibers are not covered with a myelin sheath. Because the C primary sensory fiber is unmyelinated, it has a smaller diameter and transmits signals slowly. Test-Taking Tip: Identify components of each answer choice as correct or incorrect. This may help you identify a wrong answer. p. 161

Which cognitive function is the nurse assessing when asking the patient to describe childhood teachers and important dates in life, such as an anniversary date? 1. Orientation 2. Attention span 3. Recent memory 4. Remote memory

4. Remote memory Rationale Questions regarding past events in the patient's life such as childhood teachers and important dates in life, such as an anniversary or birth date, are all asked to assess the patient's remote memory. Remote memory refers to the ability of a patient to remember verifiable events from long ago. Inability to answer these questions correctly may indicate that the patient has damage to the cerebral cortex. While assessing the orientation of the patient, the nurse asks about current time and place, such as the patient's address and phone number. While assessing the patient's attention span, the nurse can provide a series of instructions for the patient and then consider whether the patient is able to carry out the instructions properly. Inability to follow a series of instructions indicates that the patient has a decreased attention span. While assessing the recent memory of the patient, the nurse asks the patient to recall the 24-hour diet or the patient's arrival time to the facility. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

During a mental status assessment, the nurse asks about the patient's first job. Which cognitive function is the nurse assessing? 1. Orientation 2. Attention span 3. Recent memory 4. Remote memory

4. Remote memory Rationale Testing the patient's cognitive function is an integral part of the mental status assessment. Asking the patient about his or her first job is testing remote memory, because it is a verifiable past event. The nurse would ask the patient about the current date and time to test orientation. Attention span is tested by giving a set of instructions to the patient and observing whether the patient follows them properly. Recent memory can be tested by asking a question the nurse can corroborate, such as asking the patient what he or she had for breakfast. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. p. 67

Which action by the nurse is the best way to obtain a patient's family history? 1. Asking the patient's family 2. Visiting the patient's house to collect data 3. Collecting data from previous hospital visits 4. Sending a questionnaire to the patient's house

4. Sending a questionnaire to the patient's house Rationale A patient's family history includes details about the patient's family members. The best way to obtain the data is to send a detailed questionnaire to the patient when the patient makes an appointment. This practice provides ample time for the patient to gather the data, contacting other family members as needed. The nurse would obtain the family history information from the patient rather than going directly to the patient's family, because this practice may violate the patient's privacy. Not all patients live with extended families, so it may not be beneficial or appropriate for the nurse to do a home visit to collect the data. The nurse cannot rely solely on information from previous hospital visits because this information may be incomplete p.48

Which nurse is most likely to skip steps and arrive at a clinical judgment instantly during the nursing process? 1. The novice nurse 2. The competent nurse 3. The proficient nurse 4. The expert nurse

4. The expert nurse Rationale The expert nurse is more likely to arrive at a clinical judgment instantly because of the ability to recognize patterns from the assessment data. The expert nurse has an intuitive grasp of a clinical situation, possesses the ability to see salient issues in a patient situation, and knows instant therapeutic responses. The novice nurse works based on a defined, structured rule because of lack of experience. It takes 2 to 3 years in similar clinical situations to become a competent nurse. The competent nurse can work with arching goals or daily plans. After a few more years of practice, the proficient nurse can understand a patient situation as a whole rather than as a set of tasks. The proficient nurse can identify long-term goals for the patient. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as most or except in the statement. p.2

Arrange the phases of the nursing process in the order in which they are generally executed . • 1. Assessment • 2. Diagnosis • 3. Outcome identification • 4. Planning • 5. Implementation • 6. Evaluation

• 1. Assessment • 2. Diagnosis • 3. Outcome identification • 4. Planning • 5. Implementation • 6. Evaluation Rationale Although the nursing process is iterative, it follows a general sequence. The first phase of the process is the assessment phase. The nurse gathers subjective and objective data using evidence-based assessment techniques. In the diagnosis phase, the nurse identifies abnormal findings and interprets the data. The nurse then validates and documents the diagnoses. In the outcome identification stage, the nurse identifies expected outcomes that are individualized for the patient. The fourth phase of the nursing process is planning. The nurse establishes priorities, sets outcomes for the patient, and documents a plan of care for the patient. The implementation phase is the fifth phase. The nurse implements the plan of care in a safely and timely manner. The nurse evaluates the progress of the patient and may use ongoing assessment to revise diagnoses, outcomes, and plan of care. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. You are asked to arrange the steps of a nursing action. In this type of question, it may help to write the steps out on paper rather than trying to rearrange them in your head. p.3