Nurse Assessment Midterm

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? A. Subjective B. Objective C. affective D. effective

B. Objective

Which of the following is not released during the stress response? A. epinephrine B. norepinephrine C. dopamine D. cortisol

C. dopamine

The nursing class is learning about pain assessment. Which of the following is a manifestation of pain? A. confusion B. bracing C. pressured speech D. apathy

B. bracing

An assessment that concentrates on patterns of role performance that all humans share is called what? A. head to toe B. body systems C. focused D. functional

D. functional

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient? A. Knowledge deficit B. ineffective coping C. Nutrition: less than body requirements D. acute pain

A. Knowledge deficit

The nurse is using a multidimensional pain assessment tool that combines indices measuring pain intensity, mood, pain location, and verbal descriptors, and which includes questions about medication efficacy. Which of these tools is a multidimensional pain assessment tool? A. McGill pain questionnaire B. visual analog scale C. numeric pain intensity scale D. combined thermometer

A. McGill pain questionnaire

The community health nurse is caring for an older patient who states that she has not been taking the postoperative pain medication that she was prescribed. What questions is most likely to be relevant? A. are you able to afford the prescribed medication B. is confusion causing you to refuse your pain medications C. are you too busy to take your prescribed pain medication D. will you take the medication if your are offered to do so

A. are you able to afford the prescribed medication

A nurse, new to the hospital, is attending orientation with the nurse educator who is discussing the use of PIE charting in the documentation of patient care. How would the nurse educator best describe PIE charting? A. problem, interventions, and evaluation B. position, interaction, and evaluation C. position, intervention, and exit note D. problem, interventions, and exit note

A. problem, interventions, and evaluation

The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? A. promoting elaboration B. restatement C. focusing D. clarification

A. promoting elaboration

In addition to pain intensity, what is another basic element of a pain assessment? A. quality B. focused goal C. history D. preferred assessment tool

A. quality

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique? A. risk for injury B. risk for infection C. risk for chronic pain D. risk for impaired skin integrity

A. risk for injury

A patient arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this patient? A. sweet smelling breath B. hypoglycemica C. bradycardia D. O2 saturation of less than 90%

A. sweet smelling breath

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing? A. tympanic B. rectal C. oral D. axillary

A. tympanic

Durring an initial assessment of a new patient, the nurse notes that the patient's weight is 210 ln and his height is 6'0". What is the patient's body mass index? A. 28.0 B. 28.5 C. 29 D. 29.5

B. 28.5

A nurse has assessed the blood pressure of a recently admitted patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure? A. 128 mm Hg B. 78 mm Hg C. 50 mm Hg D. 103 mm Hg

B. 78 mm Hg

What is the nurse assessing when asking the patient, :What things seem to make it better?" A. druation B. aggravating/alleviating factors C. functional goal D. pain goal

B. aggravating/alleviating factors

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient? A. breathing B. airway C. circulation D. disability

B. airway

Why is accurate and effective documentation most important? A. it keeps patients informed about their care B. documentation constitutes a legal record C. it ensures that data can be used for research purposes D. it can be used to educate other nurses

B. documentation constitutes a legal record

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens? A. use of alcohol based hand cleanser B. respiratory/cough hygiene C. how to recycle personnel protective equipment D. how to clean patient equipment

B. respiratory/cough hygiene

A patient comes to the ED complaining of chest pain. This would be considered A. subjective secondary data B. subjective primary data C. objective secondary data D. objective primary data

B. subjective primary data

A nurse is taking a rectal temperature on an unconscious patient. What reading would reflect temperature within the normal range? A. 97 F B. 98 F C. 99 F D. 100 F

C. 99 F

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides? A. Data on the patients prognosis for recovery. B. Information on the effectiveness of interventions C. A baseline for comparison with future findings. D. Information on the nurse's cultural competence.

C. A baseline for comparison with future findings

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? A. functional B. focused C. head to toe D. body system

C. Head to toe

Light palpation is most appropriate to assess the A. appendix B. bladder C. inflamed areas of the skin D. liver

C. Inflamed areas of the skin

A nurse is explaining to other nurses on the unit about diagnosis-related groups. On what documentation do insurance companies base their payment approval/disapproval? A. medical diagnosis B. laboratory tests C. diagnosis codes D. narrative notes

C. diagnosis codes

The nurse is having trouble obtaining the pulse and BP in a patient who is in shock. What device would assist the nurse in obtaining the needed vital signs? A. vital signs monitor B. sphygmomanometer C. doppler ultrasound D. pulse oximeter

C. doppler ultrasound

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? A. sympathy B. therapeutic communication C. empathy D. caring

C. empathy

The nurse is working on a pediatric unit caring for a 4 year old who is recovering from the surgical repair of the pelvis. When assessing the patient's pain, what is the most appropriate pain assessment tool for the nurse to use? A. face, legs, activity, cry, consolability scale B. visual analog scale C. faces pain scale D. numeric pain intensity scale

C. faces pain scale

When the nurse questions a patient about sitting, rising from a chair, standing for periods, climbing stairs, shopping, driving, and participating in sports, what is he or she assessing? A. pain goal B. quality C. function D. duration

C. function

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs? A. Resonant B. tympanic C.hyperresonanant D. flat

C. hyperresonanant

When you observe the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing? A. palpating B. interviewing C. inspecting D. auscultating

C. inspecting

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? A. it maximizes compliance with standards of documentation B. it disables the graphing of trends in vital signs or assessment data C. it allows several health team members to view the patient record simultaneously D. it automatically corrects both spelling and grammar

C. it allows several health team members to view the patient record simultaneously

What statement about batch charting is most accurate? A. it provides clear documentation B. it makes the chart available to multiple users C. it contributes to many potential errors D. it facilitates completion in a timely manner

C. it contributes to many potential errors

You should use the bell of the stethoscope when auscultating what type of sounds? A. abnormal sounds B. high-frequency sounds C. low-frequency sounds D. liver

C. low-frequency sounds

One technique of therapeutic communication is silence. What does silence allow the patient to do? A. learn to trust the nurse B. change topics if he or she wants C. communicate concerns nonverbally D. decide how much information to disclose

D. Decide how much information to disclose

Student nurses are learning about evidence based practice. What would they learn is the final step in this process? A. searching the literature for research B. evaluating research evidence using their own criteria C. identifying the issue or problem based on an analysis of current nursing knowledge and practice D. Justifying the selection of interventions

D. Justifying the selection of interventions

What are various measurements of the human body, including height and weight, called? A. datum B. vital measurements C. anthropomorphic D. anthropometric

D. anthropometric

The nurse i caring for a patient who is experiencing visceral pain. What is this patient's most likely diagnosis? A. shingles B. bone fracture C. myocardial infarction D. appendicitis

D. appendicitis

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance? A. patient level B. shift level C. department level D. facility level

D. facility level

A new graduate nurse is having trouble charting the details of a shift assessment on a patient. The preceptor of the new nurse explains to the nurse that accurate descriptions are essential for A. setting the patient's expectations B. facilitating clear communication C. maximizing the efficiency of care D. legal documentation

D. legal documentation

While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose? A. to summarize the converstaion B. to restate what the patient has said C. to promote objectivity D. to clarify

D. to clarify

The nurse is caring for a patient with a terminal illness. What would be the purpose of convening a family care conference? A. to agree on when care begins B. to coordinate schedules C. to determine what assessment data to include in a report D. to coordinate all aspects of the patient's care

D. to coordinate all aspects of the patient's care

The nurse is taking a comprehensive health history on a new patient. Why wold it be essential for the nurse to obtain a complete description of the present illness. A. to assess if the patient is a reliable historian B. to obtain primary data C. to obtain demographic data D. to establish an accurate diagnosis

D. to establish an accurate diagnosis

The nurse is conducting a general survey of a patient new to the clinic. In what part of the survey would the nurse assess the hair distribution on the patient's body? A. when assessing the body structure and development B. when assessing the posture C. when assessing the range of motion D. when assessing the skin

D. when assessing the skin