Exam 1: Health assessment and mental health (mood/affect)
A patient complains of leg pain. Which question is pertinent to ask to gain additional information? 1 "What were you doing when the pain first occurred?" 2 "How do you feel about having this pain?" 3 "Do you think the pain is caused by a cramp?" 4 "Has anyone in your family ever had similar pain?"
1 "What were you doing when the pain first started?"
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission? 1 A comprehensive assessment 2 A problem-based health assessment 3 An episodic assessment 4 A screening assessment for colorectal cancer
1 A comprehensive assessment
Which communication technique conveys genuine interest in what the patient has to say? 1 Active listening 2 Sitting close to the patient 3 Maintaining professional dress and conduct 4 Holding the patient's hand during the interview
1 Active listening
Which process does the clustering of data facilitate? 1 Analyzing data 2 Collecting data 3 Implementing nursing care 4 Evaluating nursing care
1 Analyzing the data
The nurse records the following general inspection findings on a patient: "41-year-old Hispanic male in no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than stated age. Patient with flat affect and makes minimal eye contact." What additional information should be added to this general inspection? 1 Body movement 2 Family history 3 Estimated size of his liver 4 Palpation of pulses
1 Body movement
A nurse is assessing a woman whose religious beliefs do not allow blood transfusions. She has severe anemia, is very weak, and has altered mental status. What behavior by the nurse is needed to provide effective care to this woman? 1 Examine his or her own feelings about the importance of religious beliefs in making decisions about life. 2 Recognize that he or she cannot provide care to patients whose religious beliefs endanger their lives. 3 Try to convince the patient to have a blood transfusion to save her own life. 4 Determine whether the patient is competent to make her own decisions about health care.
1 Examine his or her own feelings about the importance of religious beliefs in making decisions about life.
Which finding is expected when assessing an 11-year-old child? 1 Five-pound (2.3 kg) weight gain and beginning of a growth spurt 2 Loss of deciduous teeth and eruption of permanent teeth 3 Development of mature relationships and beginning of dating 4 Acting out feelings during play and sports
1 Five-pound weight gain and beginning of growth spurt
A patient complains of leg pain. Which question is pertinent to ask to gain additional information? A. "What were you doing when the pain first occurred?" B. "How do you feel about having this pain?" C. "Do you think the pain is caused by a cramp?" D." Has anyone in your family ever had a similar pain?"
A
A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? A. Wheals B. Bullae C. Tumors D. Plaques
A
A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. What is the best way for the nurse to assess for jaundice in this patient? A. inspect the color of the sclera B. inspect genitalia for color C. blanch the fingernails D. jaundice cannot be assessed in patients with darkly pigmented skin
A
A nurse is teaching a family from Guatemala about the importance of exercise to reduce body weight. The husband asks, "What exercise do we do?" Considering the time orientation of this family, which response by the nurse is most effective? 1 "In the past research has shown that walking 30 minutes most days of the week is best." 2 "Is there an exercise that you can do today for 30 minutes and make it part of your daily routine?" 3 "If you exercise 30 minutes most days of the week, you can lose weight by your next visit." 4 "I have always found that resistance weight training each day for 30 minutes is effective."
2 "Is there an exercise that you can do today for 30 minutes and make it part of your daily routine?"
The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? 1 "How often do you visit the medicine man for your health care?" 2 "Tell me about your health care beliefs and practices." 3 "Many Navajo people are afraid of hospitals. Are you afraid?" 4 "Have you ever had a physical examination with a physician or a nurse practitioner?"
2 "Tell me about your health care beliefs and practices."
A patient complains of chest pain. Which question is pertinent to ask to gain additional information? 1 "What were you doing when the pain first occurred?" 2 "What does the pain feel like?" 3 "Do you have shortness of breath with the chest pain?" 4 "Has anyone in your family ever had similar pain?"
2 "What does the pain feel like?"
A school nurse notices a boy with a bandage on his arm and black fluid under the edge of the bandage. She asks the teen what happened to his arm. He replies that his mother applied axle grease to a boil. What is the nurse's most appropriate response to this boy? 1 Tell the teen to remove the bandage and wash his arm. 2 Ask the teen what the boil looks like, what it feels like, and if the axle grease is helping it get better. 3 Advise the teen to tell his mother to use antibiotic cream rather than axle grease. 4 Suggest that the teen see a health care provider because the axle grease will infect the boil.
2 Ask the teen what the boil looks like, what it feels like, and if the axle grease is helping it get better.
The formation of a plan of care is initiated with: 1 Analysis of data 2 Collection of data 3 Clustering of data 4 Identification of nursing diagnoses
2 Collection of data
A female has been admitted to the emergency department with severe abdominal pain. She is lying on a stretcher quietly, with very little movement. The nurse preparing to assess her abdomen should expect to see which behavior when it is time to palpate this patient's abdomen? 1 Flushing of the face and neck 2 Guarding over the abdomen 3 Relaxation of abdominal muscles 4 Decreased peristalsis
2 Guarding of the abdomen
During an interview the nurse learns that a patient has a 5-year history of hypertension. Which health promotion intervention is most appropriate at this time? 1 Teaching the patient how to relieve stress to prevent hypertension 2 Monitoring and minimizing the progression of hypertension 3 Establishing a screening schedule for detection of hypertension 4 Advising the patient on the benefits of exercise to lower blood pressure
2 Monitoring and minimizing the progression of HTN
A patient had a knee replaced because of arthritis. He reports that he has not slept well in several nights. He states that he can't get comfortable. Today he is asking for pain medication more often. What might be a reason for this increase in pain? 1 Arthritis pain is variable; it can be mild one day and severe the next. 2 Pain tolerance decreases with sleep deprivation. 3 The anesthesia from surgery is wearing off. 4 The patient is using the pain medication to help him sleep during the day
2 Pain tolerance decreases with sleep deprivation
The nurse obtains vital signs on a 42-year-old man having his annual physical examination. He has no medical conditions and states that his health is excellent. His blood pressure appears as 62/40 using an automated blood pressure device. Which action by the nurse is most appropriate? 1 Obtain a different cuff and take the blood pressure again. 2 Take the blood pressure again using the auscultation method. 3 Place the patient in a supine position and take the pressure on the leg. 4 Record the blood pressure and continue with the examination.
2 Take the blood pressure again using the auscultation method.
Which immunizations does the nurse ask about when interviewing a 75-year-old patient? 1 Measles, mumps, and rubella 2 Tetanus and influenza 3 Hepatitis B and varicella 4 Inactivated polio vaccine
2 Tetanus and influenza
Which statement reflects an expected developmental task of a 40-year-old man? 1 "I'll be completing my degree this year, and then I plan to marry my fiancé." 2 "I'm staying active with plenty of volunteer activities every day of the week." 3 "My wife and I have divided the chores with the children since we're both working." 4 "My life is going to be different now that dad has died and the care of mom is my responsibility."
3 "My wife and I have divided the chores with the children since we're both working."
The nurse is caring for a woman who has just been pronounced dead. Her adult children are in the room. Which statement by the nurse indicates culturally competent care? 1 "Which funeral home would you like notified of your mother's death?" 2 "We will be moving her to the morgue in about 30 minutes." 3 "Would you like time alone with your mother for any specific ceremonies?" 4 "Here are some of her personal belongings that were in the drawer."
3 "Would you like time alone with your mother for any specific ceremonies?"
A nurse is assessing an infant who is able to pull up to a sitting position, turn from prone to side position, laugh and babble, and show interest in her surroundings. These behaviors are consistent with an infant of which age? 1 7 months old 2 5 months old 3 3 months old 4 1 month old
3 3 months old
Which set of vital signs should the nurse recognize as out of the expected range? 1 42-year-old man: BP, 114/82; pulse, 74 beats/min; respiration, 16 breaths/min; temperature, 36.8° C 2 11-year-old girl: pulse, 88 beats/min; respiration, 22 breaths/min; temperature, 36.7° C 3 3-year-old boy: pulse, 130 beats/min; respiration, 44 breaths/min; temperature, 36.7° C 4 1-month-old girl: pulse, 120 beats/min; respiration, 42 breaths/min; temperature, 36.7° C
3 3-year-old boy: pulse, 130 beats/min; respiration, 44 breaths/min; temperature, 36.7° C
During an interview an elderly patient tells the nurse that she has periodic problems keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom analysis is the nurse pursuing with this question? 1 Severity 2 Frequency 3 Aggravating factors 4 Location
3 Aggravating Factors
An older man who is near death has been admitted to the hospital, and family members are at his bedside. During the admission assessment the nurse uses which question or statement to appropriately address spiritual needs? 1 What is your religion? I'll make the appropriate spiritual arrangements? 2 Tell me what death means to people from your culture. 3 Are there any special needs or rituals that you and your family request at this time? 4 I'll call the hospital priest so he can administer last rites.
3 Are there any special needs or rituals that you and your family request at this time?
A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? 1 He has a family history of liver disease. 2 There has been a scabies outbreak among his family members. 3 He has a new full-time position as a dishwasher at a local restaurant. 4 He had several warts removed from his hands 2 years ago.
3 He has a new full-time position as a dishwasher at a local restaurant.
A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What type of data does this information represent? 1 Subjective data 2 Objective data 3 Subjective and objective data 4 Secondary source data
3 Subjective and objective data
A patient is brought to the emergency department with severe respiratory distress. Which method of temperature measurement would be most appropriate? 1 Oral temperature with an electric thermometer 2 Axillary with an electronic thermometer 3 Temporal artery 4 Rectal temperature
3 Temporal artery
A 62-year-old patient tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patient's statement? 1 "Do you avoid taking drugs because of bad experiences?" 2 "Which medications have you taken in the past?" 3 "That is hard to believe. Most men your age take medications." 4 "Do you use over-the-counter medications or herbal preparations?"
4 "Do you use over-the-counter medications or herbal preparations?"
The nurse is conducting an interview with Jeremy, a 17-year-old accompanied by his mother. Which statement by the nurse is an age-appropriate adjustment when conducting a health history on an adolescent? 1 "Jeremy, do you have a girlfriend, and if so are you sexually active yet?" 2 "Mrs. Williams, is your son sexually active yet?" 3 "Jeremy, how do you incorporate safe sex practices into your daily life?" 4 "Mrs. Williams, would you mind waiting outside for a few minutes while I discuss a few things with Jeremy?"
4 "Mrs. Williams, would you mind waiting outside for a few minutes while I discuss a few things with Jeremy?"
A 15-year-old boy approaches the school nurse and describes how uncomfortable he is around the girls because most of them are taller than he is. What is the nurse's best response to this adolescent? 1 "Let's discuss your diet to determine if you are eating enough nutrients." 2 "Genetics play an important part in height; if your parents are short, you may be short as well. 3 "Sleep is necessary for growth. Are you getting adequate sleep?" 4 "The growth spurt during adolescence occurs in girls 18 to 24 months before it occurs in boys."
4 "The growth spurt during adolescence occurs in girls 18 to 24 months before it occurs in boys."
A 62-year-old patient tells the nurse that he has recently had frequent fainting spells. After palpating the radial pulse, 13 pulsations are counted in 15 seconds. The nurse determines that the patient has a pulse rate of 52, with a regularly irregular rhythm. What is the most appropriate action for the nurse to take at this time? 1 Reassess the pulse rate after he walks around the room for several minutes. 2 Reassess the pulse rate for 15 seconds using the carotid artery. 3 Take an apical pulse for 5 full minutes, counting the number of skipped beats. 4 Palpate the pulse for a full minute and note whether there is a pattern to the irregularity.
4 Palpate the pulse for a full minute and note whether there is a pattern to the irregularity.
What is the most reliable way to assess a patient's pain? 1 Type and frequency of analgesic medications the patient takes 2 Patient's most recent vital signs (e.g., blood pressure and pulse rate) 3 Extent of tissue damage the patient has had 4 Report from the patient describing the pain experienced
4 Report from the patient describing the pain experienced
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission? A. Comprehensive assessment B. Problem-based health assessment C. Episodic assessment D. Screening assessment for colorectal cancer
A
A nurse is assessing a woman whose religious beliefs do not allow blood transfusions. She has severe anemia, is very weak, and has altered mental status. What should the nurse do to provide culturally competent care to this woman? A.Examine his or her feelings about the role of religious beliefs in making decisions about life B. Recognize that he or she cannot provide care to patients whose religious beliefs endanger their lives C. Try to convince the patient to have a blood transfusion to save her own lifee D. Determine whether the patient is competent to make her own decisions about health care
A
Auscultation is a component is a component of which examination technique? A. blood pressure movement B. visual acuity C. examination of the ears D. measurements of oxygen saturation
A
During a history the patient says that she is so uncomfortable with her life that she wishes that it were over. Which is an appropriate follow-up question from the nurse? A. "Have you thought of hurting yourself?" B. "Oh, I've felt that way many times." C. "That feeling will go away; just give it some time." D. "In which ways has you life been uncomfortable?"
A
During a sports physical a 16 year old girl, the nurse asks which questions about drug use? A. many teenagers have tried street drugs. Have you tried any?" B. "Tell me which street drugs your friends have offered you." C." Do your friends tell you about the street drugs they use?" D." Your high school has a reputation for students using street drugs. Do you use these drugs?"
A
Narrowing of the bronchi creates which adventitious sounds? A. Wheeze B. Crackles C. Rhonci D. Pleural friction rub
A
On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? A. Rhonchi B. Wheeze C. Crackles D. Pleural friction rub
A
Select the example given below that represents information a nurse collects from a patient during a physical examination A. shiny skin and lack of hair found on lower legs B. concerned about lack of money to pay for prescriptions C. complains of tingling in both feet while sleeping D. family history of colon and breast cancer
A
The nurse records the following general inspection findings on a patient: "41 year old Hispanic male in no distress; very thing, skin tone slightly jaundiced, disheveled appearance and appears older than his states age. Patient with flat affect and makes minimal eye contact." What additional information should be added to this general inspection? A. his body movement B. the family history C. estimated size of his liver D. his pulse rate
A
Which breath sounds are expected over the posterior chest of an adult? A. Vesicular B. Bronchovesicular C. Bronchial D. Bronchoalveolar
A
Which communication technique conveys genuine interest in what the patient has to say? A. active listening B. sitting close to the patient C. maintaining professional dress and conduct D. holding the patients hand during the interview
A
While examining a patient with an infected abdominal incision, the nurse notices that it is very malodorous. Which technique does this represent? A. inspection B. palpation C. auscultation D. percussion
A
The student nurse is preparing to assess a patient in the hospital clinical setting. Which components best describe the concept of health assessment? Select all that apply: A. Collection of objective data B. Collection of subjective data C. Collection of data and identification of ND D. Planning and evaluation of data E. Analysis of data F. Physical exam G. Documentation of data
A B E F
The nurse is conducting a data analysis on objective information obtained during the health history. What should be included? Select all that apply: A. Vital signs B. Pain assessment C. Review of symptoms D. Surgical History E. Social history F. Heart murmur
A F
Which is a common mistake made by health care professionals when collecting data about ethnic and cultural considerations of a patient?
Assuming data about the patient based on skin color or ethnic group
A female has been admitted to the ER with severe abdominal pain. She is lying on a stretcher quietly, with very little movement. Which patient response should the nurse anticipate when palpating this patient's abdomen? A. Flushing of the face and neck B. Guarding over the abdomen C. Redness on the lower abdominal quadrants D. Decreased peristalis
B
A nurse is teaching a family from Guatemala about the importance of exercise to reduce body weight. The husband asks, "What exercise should we do?" Considering the time orientation of this family, what is the most effective way for the nurse to respond?" A."Research has shown that walking 30 minutes most days of the week is best." B. "Is there an exercise that you can do today for 30 minutes and add it to your daily routine?" C. "If you exercise 30 minutes most days of the week you can lose weight by your next visit." D. "I have always found that resistance weight training each day for 30 minutes is effective."
B
A patient had a knee replaced because of arthritis. He reports that he has not slept well for several nights. He states that he can't get comfortable. Today he is asking for pain medication more often. What could be a reason for this increase in pain? A. Arthritis pain is variable; it can be mild one day and severe the next B. Pain tolerance decreases with sleep deprivation C. Anesthesia from surgery is wearing off D. The patient is using the pain medication to help him sleep during the day
B
The student nurse is learning how to obtain blood pressures and is studying what factors can affect blood pressure. What should the student nurse include as factors that affect blood pressure? Select all that apply: A. What the person ate B. Smoking C. Mobility D. Race E. Gender F. Weight G. Pain
B D E F G
A school nurses notices a boy with a bandage on his arm and black fluid under the edge of the bandage. She asks the teen what happened to his arm. He replies that his mother applied axle grease to a boil. What is the nurse's most appropriate response to this boy? A. tell the teen to remove the bandage and wash his arm B. ask the teen what the boil looks like and feels like and if the axle grease is healing the boil C. advise the teen to tell his mother to use antibiotic cream rather than axle grease D. suggest that the teen a health care provider because the axle grease will infect the boil
B
After collecting data, the nurse begins data analysis with which activity? A. documenting information from the history B. organizing the data collected C. reporting data to other care providers D. recording data from the physical examination
B
The nurse is caring for a patient with a femur fracture. An immobilization device is used to maintain the alignment of the femur. The nurse palpates the top of the foot to make which determination? A. amount of drainage from the wound B. adequacy of blood perfusion to the foot C. presence of air in the underlying tissue D. range of motion to the foot
B
The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? A. "How often do you visit the medicine man for your health care?" B. Tell me about your health care beliefs and practices." C. "Many Navajo people are afraid of hospitals. Are you afraid?" D. "Have you ever had a physical examination with a physician or nurse practitioner?"
B
The nurse is taking a patient's oral temperature. How should the nurse perform the procedure? The thermometer should be placed: A. Under the tongue next to the frenulum of the lower lip. B. Under the tongue in the posterior sublingual pocket C. Between the tongue and the hard palate D. Along the outer aspect of the lower molars and against the cheek
B
The nurse observes multiple red circular lesion with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? A. Gyrate and linear B. Annular and generalized C. Iris and discrete D. Oval and clustered
B
The nurse obtains vital signs on a 42 year old man having his annual physical examination. He has no medical conditions and states that his health is excellent. Using an automated blood pressure device, his blood pressure is measured as 62/40. Which action by the nurse is most appropriate? A. obtain a different cuff and take the blood pressure again B. take the blood pressure again using the auscultation method C. place the patient in a supine position and take the pressure on the leg D. record the blood pressure and continue with the examination
B
Which question is appropriate for a nurse to ask at the beginning of a mental health history? A. "Have you been feeling anxious or sad?" B. "How have you been feeling about yourself?" C. "Are you alone a lot, or do you socialize with friends?" D. "How are you dealing with the stressors in your life?"
B
Which situation illustrates a screening assessment? A. a patient visits a clinic for the first time and the nurse completes a history and physical examination B. hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol level C. a nurse at an urgent care center checks the blood pressure, pulse, temperature, and respirations of a patient reporting leg pain D. a patient with diabetes mellitus comes to the laboratory to get her blood glucose prior to a visit with a health care provider
B
Which technique does a nurse use to assess the mental status of patients? A. Ask them about any of their relatives who have mental health disorder B. Have them calculate the change to expect after making a purchase C. Ask them to recall how they cope with stress on a daily basis D. Have them describe the moods and emotions they experience
B
A 48 year old woman asks the nurse how to best protect herself from exessive sun exposure while at the beach. Which response would be most appropriate? A. Limit your time in the sun to 5 minutes every hour. B. Wear a wet suit that covers your arms and legs C. Apply a waterproof sunscreen to exposed skin surfaces; reapply at least every 2 hours. D. Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving the beach; this will provide all day coverage
C
The nurse is assessing the degree of pain or discomfort a patient is feeling. The nurse knows that this will be dependent primarily on the: A. Ability to explain the pain or discomfort B. Perception of the pain or discomfort C. Age of the individual D. Type of painful stimulus
B. Perception of the pain or discomfort
A nurse finds the patient's anteroposterior diameter of the chest to be same as the lateral diameter. Based on this finding, which additional data would the nurse anticipate? A. Bronchial breath sounds in the posterior thorax B. Decrease in respiratory rate C. Decreased breath sounds on auscultation D. Complain of sharp chest pain in inspiration
C
A nurse is caring for a woman who has just been pronounced dead. Her adult children are in the room. Which statement by the nurse indicates culturally competent care? A. "Which funeral home would you like notified of your mother's death?" B. "We will be moving her to thee morgue in about 30 minutes." C. "Would you like some time alone with your mother for any specific ceremonies?" D. "Here are some of her personal belongings that were in the drawer."
C
A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? A. White B. Yellow C. Clear D. Tinged
C
A patient complains of chest pain. Which question has the highest priority to obtain additional information? A. "What were you doing when the pain first occurred?" B. "Do you have shortness of breath with the chest pain?" C. "What does the pain feel like?" D. "Has anyone in your family ever had similar pain?"
C
A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? A. Dyspnea with diminished breath sounds bilaterally B. Asymmetric chest expansion on the right side C. Fever and tachypna with crackles over the right lower lobe D. Prolonged expiration with an occasional wheeze in right lower lobe
C
A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? A. He has a family history of liver disease B. there has been a scabies outbreak among his family memebers C. he has a new full time position as a dishwasher at a local restaurant D. he has several warts removed from his hands 2 year ago
C
A patient is brought to the emergency department in severe respiration distress. Which method of temperature measurement would be the most appropriate? A. oral temperature B. axillary temperature C. temporal artery D. rectal temperature
C
An older man who is near death has been admitted to the hospital, and his family members are at his bedside. Which question or statement should the nurse use during the admission assessment to address the spiritual needs of the patient and his family appropriately? A. "What is your religion? I'll make the appropriate spiritual arrangements?" B. "Tell me what death means to people from your culture." C. "Are there any special needs that you and your family request at this time?" D. "I'll call the hospital priest so he can administer last rites."
C
During a health history a patient says, "Stressors? Oh, yeah I have stressors. I got a promotion at work; and, with the extra income I'm going to move into a new house, but that has been delayed because my mother is in the hospital and my son is going off to college. To get through this time I just keep using my support systems, exercising, and meditating." How does a nurse interpret these comments by this patient? A. Flight of ideas B. Moderate anxiety C. Positive coping strategies D. Rationalization and denial
C
During an interview, an elderly patient tells the nurse that she has periodic problems in keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of symptom analysis is the nurse pursing? A. Severity B. Frequency C. Aggravating Factors D. Location
C
How does a nurse determine jugular vein pulsations? A. Elevates head of bed about 90 degrees and looks for jugular bein pulsation parallel to the sternocleidomastoid muscle as the head of the bed is slowly lowered B. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to side lying position C. Elevates head of bed until the external jugular bein pulsations is seen above the clavicle D. Positions patient supine and asks him or her to cough; looks for jugular vein pulsations during cough
C
On asucultation of the heart, the nurse recognizes which expected finding? A. A low-pitched blowing sound is heard over abdominal aorta B. A high pitcheed vibration is heard over base of the heart C. The S1 is louder at the apex of the heart D. The S3 sound sounds like "Ken-tuck-y"
C
The nurse documents which information in the patient's history? A. the patient is scratching his left arm B. the patient's skin feels warm C. the patient reports itching of her eyes D. the patient's temperature is 100F
C
Which assessment data are determined by the use of a goniometer? A. auscultation of fetal heart tones B. inspection of the cervix 3. measurement of joint flexion D. assessment of hearing
C
Which question gives the nurse further information about the patient's complaint of chest pain? A. "Have you had influenza immunization this year?" B." Are there environmental conditions that may affect your breathing at home?" C. "How would you describe the chest pain?" D. "Has the chest pain been interrupting your sleep?"
C
Which set of vital signs should the nurse recognize as out of expected range? A. 42 year old man; BP 114/82; pulse 74 beats/min; respiration 16 breaths/min; temperature 36.8C B. 11 year old girl; pulse 88 beat/min; respiration 22 breaths/min; temperature 36.7C C. 3 year old boy; pulse 130 beats/min, respiration 44 breaths/min; temperature 36.7C D. 1 month old girl; pulse 120 beats/min; respiration 42 breaths min; temperature 36.7C
C
While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate this patient has peripheral artery disease? A. Pitting edema of one or both feet and legs B. Increased circumference of the thighs bilaterally C. Pale, cool legs with diminshed to absent dorsalis pulses D. Pain when legs are dependent that is relieved when legs are elevated
C
The nurse notes that a child is having a great deal of difficulty adjusting to the new school year. According to Erickson's theory, personality development depends on: A. Making choices appropriate for each stage B. Mastering behavior over conflict C. Resolving conflict successfully within each stage D. Developing conflict in each of eight stages
C. Resolving conflict successfully within each stage
A 62 year old patient tells the nurse that he has recently had frequent fainting spells. After palpating the radial pulse, 13 pulsations are counted in 15 seconds with a regularly irregular rhythm. What is the most appropriate action for the nurse to take at this time? A. Reassess the pulse rate after he walks around the room for several minutes. B. reassess the pulse rate for 15 seconds using the carotid artery C. take an apical pulse for 5 full minutes, counting the number of skipped beats D. palpate the pulse for one minute and determine the pattern to the irregularity
D
A 62 year old patient tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patient's statement? A. "Do you avoid taking drugs because of bad experiences? B. Which medications have you taken in the past? C. That is hard to believe. Most men your age take medications D. do you use over the counter medications or herbal preparations?
D
A 60 year old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? A. Kaposi's sarcoma B. Malignant melanoma C. Basal cell carcinoma D. Squamous cell carcinoma
D
A patients reports nausea and vomiting and the nurse observes hand tremors, agitation, and sweating. In view of these findings. Which additional data would the nurse need to collect? A. Which fears or stressors the patient has been experiencing B. When the patient last took illegal drugs and which one was taken C. Which kinds of obsessions or compulsions the patient has been experiencing D. When the patient last drank alcohol and how much was consumed
D
During inspection of the respiratory system the nurse documents which finding as abnormal? A. Skin color consistent with patient's ethnicity B. 1:2 ratio of anteroposterior to lateral diameter C. Respiratory rate is 20 breaths per minute D. Patient leaning forward
D
How does the nurse palpate the chest for tenderness, bulges, and symmetry? A. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another B. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another C. With the tip of the fingers, palpate the skin over the chest and the alignment of vertebrae D. With the palmar surface of fingers of both hands feel the consistency of the skin over the chest and the alignment of vertebrae
D
The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient's: A. Defer temp for this age group B. oral C. Rectal D. Tympanic
D
The nurse is conducting an interview with Jeremy, a 17 year old accompanied by his mother. Which statement made by the nurse is an age-appropriate adjustment when conducting a health history with an adolescant? A. "Do you have a girlfriend, and if so are you sexually active yet? B."Mrs.Williams, is your son sexually active yet?" C."Jeremy, how do you incorporate safe sex practices into your daily life?" D. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy?"
D
The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being aucultated? A. Erb's point B. Mitral area C. Aortic area D. Pulmonic area
D
What is the most accurate technique for detecting a venous thrombosis at the bedside? A. dorsiflex the calf and note if patient complains of pain B. elevate one leg about the level of the heart to determine if the veins empty C. Palpate the pulses distal to the area of the suspected thrombosis D. Measure the thigh circumference to detect an increase from the baseline
D
What is the most reliable way to assess pain in a patient who is cognitively intact? A. type and frequency of analgesic medications the patient takes B. Patient's most recent vital signs (e.g BP and pulse rate) C. Extent of tissue damage the patient has experienced D. report by the patient describing the pain experienced
D
When examining a 16 year old male patient, the nurse notes multiple pustules and comedones on the face. The nurse recognizes that increased activity of which cells or glands produce these manifestations? A. Epidermal cells B. Eccrine glands C. Apocrine glands D. Sebaceous glands
D
Which disorder is an example of vascular lesion? A. dermatofibroma B. vitiligo C. sebaceous cyst D. port wine stain
D
Which infection control intervention is most frequently applied? A. wearing gloves B. wearing masks C. wearing eye protection D. hand hygiene
D
The nurse is assessing a 5-month-old infant to determine if the infant is meeting typical milestones. Which observation should be considered an expected finding for a 5-month-old infant? A. Stands while holding onto furniture B. Sits alone C. Head lags when pulled to sitting position D. Rolls over independently
D. Rolls over independently
A patient tells the nurse that he has had a headache and nausea for 3 days. Which type of assessment should the nurse perform?
Focused assessment
The nurse is obtaining a patient's blood pressure and suspects that the reading is a false high reading. What leads the nurse to confirm this suspicion?
Using a cuff that is too narrow