Health Assessment Exam One NCLEX questions

When interviewing, the nurse should logically move from specific to open-ended questions.

B. False

The nurse recognizes the following to a necessary component of performing an accurate assessment:

Collection and organization of data, documentation of data, and validation of data

Nonverbal communication is a very important aspect in the nurse-client relationship. What can the nurse do to help gain trust in clients? Select all that apply

Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally; do not use facial expressions such as rolling the eyes or looking bore or disgusted;. make sure that dress and appearance are professional

When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be

a. "Why do you think you have (name the specific symptom)?"

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

a. Emotional

Which of the following is a CAGE question?

a. Have you ever felt annoyed by criticism about drinking?

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

a. Primary prevention

When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the patient about alcohol use. The question most appropriate to ask next would be

b. "Do you ever drink then drive?"

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

b. "Do you have family who visit you regularly?"

A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad that an easy way to think about the anagram

b. ADPIE

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

b. Review the client's health record

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

b. Seated in a chair at eye level with the client

The experienced nurse understand that active listening is the key element when interviewing a patient

b. True

A client comes to the office for evaluation of fatigue. HE has come to the office many times in the past with various injuries, and the nurse suspects that the client has a problem with alcohol. Which of the following questions is the most helpful in diagnosing this problem?

b. When was your last drink?

During the interview process, the nurse uses both open-ended and close-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

b. Working

A nurse is providing feedback to a colleague after observing the colleague's interview of an admitted client. Which of the following would the nurse identify as an example of a close-ended question or statement?

c. "Are you allergic to any medications?"

A past history is being taken by the nurse for a patient with COPD. The nurse includes which elements in this part of the health history? Select all that apply

c. Childhood illnesses, allergies, health maintenance

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

c. Discuss the plan with the patient

When planning the interview with a patient who has diabetes mellitus, the nurse would choose which tool to help find out the patient's perspective on his illness?

c. FIFE (Feelings, Ideas, effects on Function, and Expectations)

A nurse is performing a patient assessment in the urgent care clinic. The most likely tool being used is

c. Focused assessment

When utilizing the website www.healthypeople.gov, the nurse notes completion of the first two areas in the acronym MAP-IT while working on a project for a Hispanic community within a large city. What action by the nurse would fulfill the next step in this process?

c. developing a goal for the community involved

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

d. Continuous

The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process?

d. Planning

After collecting subjective and objective data for the admission database, what is the nurse's next action?

d. Validate the client's identified problems

The nurse observes no urine output in a client's indwelling catheter drainage bag. What is the nurse's first action?

d. Verify positioning of the catheter

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to

d. a healthy lifestyle

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

d. comprehensive

Which of the following are part of the pre-interview of the nurse-patient interview? select all that apply

taking time for reflection, setting goals for the interview, and taking notes.

The principle of confidentiality is of paramount importance in the nurse-patient relationship. When should you inform the patient of whom his or her information will be shared?

d. At the beginning of the interview

A client comes to the emergency department wanting to be examined for the symptom of chest pain. While listening to the client describe his symptom in more detail, the nurse says, "Go on," them later, "Mm-hmmm." This is an example of which of the following skilled interviewing techniques?

d. Continuers

When planning a community program related to Healthy People 2020, the critical first step involves

d. Defining the community

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

d. Diagnostic reasoning skills are required to interpret data accurately

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of

d. Healthy People 2020

A comprehensive health history includes which components? Select all that apply

Past health history, Reason for seeking care, History of present illness

When gathering data for the family history portion of the health history, what would you ask about?

A. Coronary artery disease

OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process

A. False

When interviewing a patient with a language barrier, it is best to use a family member to help interpret so the patient has a level of comfort with the process

A. False

"Tell me about your pain" is an example of an open-ended question

A. True

A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the most appropriate expression for the nurse to use to clarify the expression's meaning from the client?

a. Tell me what you mean by ____?

What is the primary function of the health care team?

a. To decide the best overall care.

A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply

Reflect on thoughts before reaching a conclusion, Use past clinical experience to build on knowledge, and use rationale to support opinions and decisions

The nurse asks the patient about whether other family members have been diagnosed with diabetes. Which component of the comprehensive health history is the nurse addressing?

a. Family history

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

a. Physiologic status

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

a. Quote the client's words

The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of

a. rapid advances in biomedical knowledge and technology

The nurse has just asked a client how he feels about his emphysema. He becomes silent, folds his arms across his chest, and leans back in his chair. Then the client replies, "It is what it is." How should the nurse respond?

b. "You seem bothered by this question.

When discussing family history with a patient who is healthy expect for a current UTI requiring IV antibiotics, the patient tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner?

b. 3 circles and 3 squares with lines through 2 circles.

How does a nurse best facilitate the nursing health assessment?

b. Asking the appropriate questions

The nurse is taking a health history and the patient is describing symptoms experienced in the last few days. The nurse asks, "Have you noticed anything else that accompanies it?" The nurse's question is what part of the seven attributes of a symptom?

b. Associated manifestations

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

b. Nursing diagnosis

A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process?

b. Portraying a neutral and friendly expression

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first

b. Take a complete health history

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be

b. The doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease

When performing a health assessment, which is a basic tool that the nurse uses in the caring relationship with the client?

b. Therapeutic communication

Subjective and Objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse

b. True

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"

b. True

When clustering data, age can be a factor in determining the number of nursing diagnoses. The younger child typically has one diagnosis because he or she is more likely to have one single disease.

b. True

One characteristic of a nurse who is a critical thinker is the ability to

b. Validate information and judgments

Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35 year old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym?

c. "Does the pain come and go or is it constant?"

A patient is trying to explain how he feels about his eye problem. He pauses often during the conversation and often repeats himself when expressing his concern about his problem. After listening, the best response by the nurse would be

c. "I can understand why you feel the way you do."

When assisting a patient with health promotion, what must the nurse also nurture?

c. A healthy environment

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should

c. Avoid premature judgments about the client

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

c. Focused or problem-oriented assessment

The nurse is grouping subjective and objective data. Which data would the nurse list as subjective?

c. Headaches began 3 days ago

A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral Percocet instead of intravenous morphine. This nurse is doing which step of the nursing process?

c. Implementation

The nurse is collecting data for the comprehensive health history on a patient new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?

c. Past history

Which statement would demonstrate the correct method for writing an evaluation of a patient progress after implementing the nursing process?

c. Patient ambulated 3/3 times during a planned 8-hour period

The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing

c. Tertiary prevention

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?

c. Unable to feel his leg

A nurse knocks and enters a patient's room, makes introductions to the patient and visitors, and explains to the patient that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate?

d. "Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in 30 minutes so you can visit before you and I sit privately to talk"

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

d. Anxious appearance

The nurse gathers the following data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature of 100.6 degrees Fahrenheit orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be

d. Impaired comfort related to headache and sore throat pain

The nurse is performing a health history on a patient with mild chest pain who came to the emergency department. When asked about his allergies, the patient states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when the patient states an allergy?

d. What type of reaction did the patient experience?