NR 509 week 1 study guide Questions And Answers RATED A (LATEST VERSION) 2020
NR 509 week 1 study guide
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be.
2. A patient tells the nurse that he is very nervous, is nauseated and feels hot. These types of data would be
3. The patients record, laboratory studies, objective data, and subjective data combine to form the
A. Data base
B. Admitting data
C. Financial Statement
D. Discharge Summary
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to
A. Immediately notify the patients physician
B. Document the sound exactly as it was heard.
C. Validate the data by asking a coworker to listen to breath sounds
D. Assess it again in 20 minutes to note whether the sound is still present
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using:
B. A set of rules
C. Articles in journals
D. Advice from supervisors
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
B. The nursing process
C. Clinical knowledge
D. Diagnostic reasoning
7. The nurse is reviewing information about EBP. Which statement best reflects EBP?
A. EBP relies on tradition for support of best practices
B. EBP is simply the use of best practice techniques for the treatment of patients
C. EBP emphasizes the use of best evidence with the clinicians experience
D. The patients own preferences are not important with EBP.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem
A. Patient with postoperative pain
B. Newly diagnosed patient with diabetes who needs diabetic teaching
C. Individual with a small laceration on the sole of the foot
D. Individual with shortness of breath and respiratory distress
9. When considering priority settings of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
A. Low self-esteem
B. Lack of knowledge
C. Abnormal laboratory values
D. Severely abnormal vital signs
10. Which critical thinking skill helps see relationships among the data?
B. Clustering related cues
C. Identifying gaps in data
D. Distinguishing relevant from irrelevant
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the ________ diagnosis
12.The nursing process is a sequential method of problem solving that nurses use and includes which steps?
A. Assessment, treatment, planning, evaluation, discharge, and follow-up
B. Admission, assessment, diagnosis, treatment and discharge planning
C. Admission, diagnosis, treatment, evaluation and discharge planning
D. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems
A. Breathing, pain, and sleep
B. Breathing, sleep and pain
C. Sleep, breathing and pain
D. Sleep, pain and breathing
14. Which of these would be formulated by a nurse using diagnostic reasoning?
A. Nursing diagnosis
B. Medical diagnosis
C. Diagnostic hypothesis
D. Diagnostic assessment
15. Barriers to EBP include:
A. Nurses lack research skills in evaluating the quality of research studies
B. Lack of significant research studies
C. Insufficient clinical skills of nurses
D. Inadequate physical assessment skills
16. What step of the nursing process includes data collection by health history, physical examination and interview?
17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems?
A. Forma committee to conduct research studies
B. Post published research studies on the units bulletin boards
C. Encourage the nurse to visit the library to review studies
D. Teach the nurses how to conduct electronic searchers for research studies
18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?
A. Disease originates from the external environment
B. The individual human is a closed system
C. Nurses are responsible for a patients health state
D. Holistic health views the mind, body, and spirit as interdependent
19.The nurse recognizes that the concept of prevention in describing health is essential because
A. Disease can be prevented by treating the external environment
B. The majority of deaths among Americans under age 65 years are not preventable
C. Prevention places the emphasis on the link between health and personal behavior
D. The means to prevention is through treatment provided by primary health care practitioners
20.The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the
A. Patients history of allergies
B. Patients use of medications at home
C. Last menstrual period 1 month ago
D. 2.5 cm scar on the right lower forearm
21. A visiting nurse is making an initial home visit for a patient who has many chronic health problems. Which type of data base is most appropriate to collect in this setting?
A. A follow-up data base to evaluate changes at appropriate intervals
B. An episodic data base because of the continuing, complex medical problems of this patient
C. A complete health data base because of the nurses primary responsibility for monitoring the patients health
D. An emergency data base because of the need to collect information and make accurate diagnoses rapidly
22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
A. Patient is admitted to a long-term care facility
B. Patient has a sudden and severe shortness of breath
C. Patient is admitted to the hospital for surgery the following day
D. Patient in an outpatient clinic has cold and influenza-like symptoms
23. A patient is in the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
A. Collect a follow-up data base and then check her blood pressure
B. Ask her to read her health record and indicate any changes since her last visit
C. Check only her blood pressure because her complete health history was documented 2 months ago
D. Obtain a complete health history before checking her blood pressure because much of her history information may have changed
24. A patient is brought by ambulance to the ED with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
A. Collect history information first, then perform a physical examination and institute life-saving measures
B. Simultaneously ask history questions while performing the examination and initiating life-saving measures
C. Collect all information on the history form, including social support patterns, strengths, and coping patterns
D. Perform life-saving measures and delay asking any history questions until the patient is transferred to the ICU.
25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurses knowns that including cultural information in his health assessment is important to:
A. Identify the cause of his illness
B. Make accurate disease diagnoses
C. Provide cultural health rights for the individual
D. Provide culturally sensitive and appropriate care
26. In the health promotion model, the focus of the health professional includes:
A. Changing the patients perceptions of disease
B. Identifying biomedical model interventions
C. Identifying negative health acts of the consumer
D. Helping the consumer choose a healthier lifestyle
27. The nurse has implemented several planned interventions to address the nurses diagnosis of acute pain. Which would be the next appropriate action?
A. Establish priorities
B. Identify expected outcomes
C. Evaluate the individuals condition, and compare actual outcomes with expected outcomes
D. Interpret data, and then identify clusters of cues and make inferences
28. Which statement best describes a proficient nurse? A proficient nurse is one who:
A. Has little experience with a specified population and uses rules to guide performance
B. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution
C. Sees actions in the context of daily plans for patients
D. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient
29. A nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply
A. Inspiratory wheezes noted in left lower lobe
B. Hypoactive bowel sounds
C. Nonproductive cough
D. Edema 2 noted on the left hand
E. Patient reports dyspnea upon exertion
F. Rate of respirations 16 breaths per minute
30. Put the following situations in order according to the level of priority
A. A patient newly diagnosed with type 2 DM does not know how to check his own blood glucose levels with a glucometer
B. A teenager who was stung by a bee during soccer match is having trouble breathing
C. An older adult with a urinary tract infection is also showing signs of confusion and agitation
1. First-level priority problem (B)
2. Second-level priority problem (C)
3. Third-level priority problem (A)
31. The nurse is conducting an interview what a woman who has recently learned that she is pregnant and who has come to the clinic today to being prenatal care. The woman states that she and her husband are excited about the pregnancy, but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:
A. Excited about her pregnancy but nervous about the labor
B. exhibiting verbal and nonverbal behaviors that do not match
C. Excited about her pregnancy, but her husband is not in this is upsetting to her
D. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.
32. Receiving is a part of the communication process. which receiver is most likely to misinterpret a message sent by a Health care professional?
A. Well-adjusted adolescent who came in
B. Recovering alcoholic who came in for a basic physical exam
C. Man whose wife has just been diagnosed with lung cancer
D. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him
33. The nurse makes which adjustment in the physical environment to promote success of an interview?
A. Reduces noise by turning off televisions and radios
B. Reduces the distance between the interviewer and patient to 2 feet or less
C. Provides a dim light that makes the room cozy and helps the patient relax
D. Arrange is sitting across a desk or table to allow the patient some personal space
34. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding notetaking
A. Note taking may impede the nurses observation of the patients nonverbal behaviors
B. Note taking allows the patient to continue at his or her own pace as the nurse records what is said
C. Note taking allows the nurse to shift attention away from the patient resulting in an increased comfort level
D. Note taking allows a nurse to break eye contact with the patient which may increase his or her level of comfort
35. The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the ______ Phase of the interview process.
D. Opening or introduction
36. A woman has entered the emergency Department after being battered by her husband. the nurse needs to get some information from her to begin treatment. what is the best choice for an opening phase of the interview with this patient?
A. Hello, Nancy, my name is Mrs. C
B. Hello, Mrs. H, my name is Mrs. C. It sure is cold today!
C. Mrs. H, my name is Mrs. C. How are you?
D. Mrs. H, my name is Mrs. C. I'll need to ask you a few questions about what happened
37. During an interview, the nurse states, you have mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement?
C. Direct question
D. Open ended question
38. A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some of the information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate together these data?
A. Mr. Y, at your age, surely you have been hospitalized before!
B. Mr. Y, I just need permission to get your medical records from County medical
C. Mr. Y you mentioned that you have been hospitalized on several occasions. would you tell me more about that?
D. Mr. Y, I just need to get some additional information about your past hospitalizations when was the last time you were admitted for chest pain
39. In using verbal responses to assist the patient's narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be:
40. When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior?
A. Be silent, and allow him to continue when he is ready
B. Smile at him and say, don't worry about all of this. I'm sure we can find out why you are having these pains.
C. Lean back in the chair and ask, you are looking at me kinda funny; There isn't anything wrong, is there?
D. Stand up and say, I can see this interview is uncomfortable for you. We can continue it another time.
41. A woman is discussing the problems she is having with her 2 year old son. She says, he won't go to sleep at night and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be:
A. Go on, I'm listening
B. Fits? Tell me what you mean by this.
C. Yes, it can be upsetting when a child has a fit.
D. Don't be upset with me has a fit, every 2 year old has fits
42. A 17-year-old single mother is describing how difficult it is to raise a 3 year old child by herself. During the course of the interview she states, I can't believe my boyfriend has left me to do this by myself. What a terrible thing to do to me. Which of these responses by the nurse uses empathy?
A. You feel alone.
B. You can't believe he left you alone?
C. It must be so hard to face this all alone.
D. I would be angry too, raising a child alone is no picnic
43. A man has been admitted to the Observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
A. Mr. K. I know that you are lying
B. Mr. K, come on, tell me how much you smoke
C. Mr. K, I did not realize your wife had died. It must be difficult for you at this time. Please tell me more about that.
D. Mr. K, you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket.
44. The nurse has used interpretation regarding a patient statement or actions. after using this technique, it would be best for the nurse to:
A. Apologize, because using interpretation can be demeaning for the patient
B. Allow time for the patient to confirm or correct the inference
C. Continue with the interview as though nothing has happened
D. Immediately restate the nurse's conclusion on the basis of the patients nonverbal response
45. During an interview, a woman says, I have decided that I can no longer allow my children to live with their father's violence. But I just can't seem to leave him. Using interpretation, the nurses best response would be
A. Are you going to leave him?
B. If you are a frayed for your children, then why can't you leave?
C. It sounds as if you might be afraid of how your husband will respond.
D. It sounds as though you have made your decision. I think it is a good one.
46. A pregnant woman states, I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, oh don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was :
A. Therapeutic response. By sharing something personal, the nurse gives hope to this woman
B. Non-therapeutic response. By Providing false reassurance, the nurse actually cut off further discussion of the woman's fears
C. Therapeutic response. By providing information about medications available, the nurse is giving information to the woman.
D. Non therapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.
47. During a visit to the clinic, patient states, the doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I have tried. I just don't know the best way to do it. What should I do? The nurse is most appropriate response in this case would be :
A. I'd quit if I were you. The doctor really knows what he is talking about
B. Would you like some information about the different ways a person can quit smoking?
C. Stopping your dependence on cigarettes can be very difficult. I understand how you feel.
D. Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer?
48. As the nurse enters a patient's room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, I'm so afraid, um, you know. The nurse is most therapeutic response would be to say in a gentle manner:
A. You are afraid you might lose your breast?
B. No, I'm not sure what you are talking about.
C. I'll wait here until you get yourself under control, and then we can talk.
D. I can see that you are very upset. Perhaps we should discuss this later period
49. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, you don't smoke, drink, or take drugs, do you? This question is an example of:
A. Talking too much
B. Using confrontation
C. Using biased or leading questions
D. Using blunt language to deal with distasteful topics
50. When observing a patient verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should :
A. Ask someone who knows the patient well to help interpret this discrepancy
B. Focus on the patient's verbal message and try to ignore the nonverbal behaviors
C. Try to integrate the verbal and nonverbal messages and then interpret them as an average
D. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patients true feelings
51. During an interview, a parent of a hospitalised child is sitting in an open position. And the interviewer begins to discuss his son's treatment, suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
A. Simply changing positions
B. More comfortable in this position
C. Tired and need a break from the interview.
D. Uncomfortable talking about his son's treatment
52. A mother brings her 28-month-old daughter into the clinic for a well child visit. At the beginning of the visit the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and a smiling shyly at the nurse. The nurse will be most successful and interacting with the toddler if which is done next?
A. Tickle the toddler get her to laugh
B. Stoop down to her level and ask her about the toys she is holding.
C. Continue to ignore her until it is time for the physical examination
D. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view
53. During an examination of a 3 year old child, the nurse will need to take her blood pressure. What might think nurse do to try to gain the child's full cooperation?
A. Tell the child that the blood pressure cuff is going to give her arm a big hug
B. Tell the child that the blood pressure cuff is asleep and cannot wake up
C. Give the blood pressure cuff a name and refer to it by this name during the assessment
D. Tell the child that by using the blood pressure cuff we can see how strong her muscles are.
54. A 16 year old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him?
A. use periods of silence to communicate respect
B. Be totally honest with him even if the information is unpleasant
C. Tell him that everything that is discussed will be kept totally confidential
D. Use slang language when possible to help him open up
55. A 75-year-old woman is at the office for a pre-op interview. The nurse is aware that the interview may take longer then interviews with younger persons. What is the reason for this?
A. An aged person has a longer story to tell
B. An aged person is usually lonely and likes to have someone with whom to talk
C. Aged persons lose much of their mental abilities and require longer time to complete an interview
D. As a person ages he or she is unable to hear, best the interviewer usually means to repeat much of what is said
56. The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?
A. Determine the communication method he prefers
B. Avoid using facial and hand gestures because most hearing impaired people find this degrading
C. Request a sign language interpreter before meeting with him to help facilitate the communication
D. Speak loudly with exaggerated facial movement when talking with him because doing so will help him lip read
57. During a prenatal check, a patient begins to cry as the nurse asked her about previous pregnancies. She says that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be :
A. I am so sorry for making you cry
B. I can see that you are sad remembering this. It is alright to cry
C. Why don't I stepped out for a few minutes until you are feeling better
D. I can see that you feel sad about this, why don't we talk about something else.
58. A female nurse is interviewing a man who has recently immigrated. During the course of the interview he leaned forward and then finally moves his chair close enough that his knees are nearly touching the nurse's knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next
A. The nurse should try to relax, these behaviors are culturally appropriate for this person
B. Cleaner should discretely move his or her chair back until the distance is more comfortable and then continue with the interview
C. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors
D. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away
59. A female American Indian has come to the clinic for follow up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. which statement is true regarding the situation?
A. The woman is nervous and embarrassed
B. She has something to hide and is ashamed
C. The woman is showing inconsistent verbal and nonverbal behaviors
D. She is showing that she is carefully listening to what the nurse is saying
60. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?
A. Do you take medicine
B. Do you sterilize the bottles?
C. Do you have nausea and vomiting?
D. You have been taking your medicine, haven't you?
61. A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview?
A. How is your family?
B. How is your job?
C. Tell me about your hypertension.
D. How has your health been since your last visit?
62. The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment?
A. This comment is inappropriate because it shows the nurses blame him
B. This comment is appropriate because members of the health care team are experts in their area of patient care
C. This type of comments promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation
D. Using authority statements when dealing with patients, especially when they are undecided about an issue comment is Necessary at times
63. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
A. Trained interpreter
B. Male family member
C. Female family member
D. Volunteer college student from the foreign language studies Department
64. During a follow up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asked, why haven't you taken your insulin? Which statement is an appropriate evaluation of this question?
A. this question may place the patient on the defensive
B. this question is an innocent search for Information
C. discussing his behavior with his wife would have been better
D. A direct question is the best way to discover the reasons for his behavior
65. The nurse is nearing the end of an interview. Which statement is appropriate at this time?
A. Did we forget something?
B. Is there anything else you would like to mention?
C. I need to go on to the next patient. I'll be back
D. While I'm here, let's talk about your upcoming surgery.
66. During the interview portion of data collection, the nurse collects the ______ data.
67. During an interview, the nurse would expect that most of the interview will take place at what distance?
A. Intimate zone
B. Personal distance
C. Social distance
D. Public distance
68. A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overly sexual comment. The nurses best reaction would be
A. Stop that immediately!
B. Oh, you are too funny. let's keep going with the interview.
C. Do you really think I would be interested?
D. It makes me uncomfortable when you talk that way. please stop.
69. The nurse is conducting an interview. Which of these statements is true regarding open ended questions? Select all that apply.
A. Open ended questions elicit cold facts
B. They allow for self-expression
C. Open ended questions build an enhance rapport
D. They leave interactions neutral
E. Open ended questions call for short 1-2 word answers
F. They are used when narrative information is needed
70. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this Situation? select all that apply.
A. Collect the patience data and a direct face to face manner
B. Enter all the data as the patient states them
C. Ask the patient to wait as a nurse enters the data
D. Type the data into the computer after the narrative is fully explored
E. Allow the patient to see the monitor during typing
71. When evaluating a patient's pain, the nurse knows that an example of acute pain would be
A. Arthritic pain
C. Kidney stones
D. Low back pain
72. Which statement indicates that the nurse understands the pain experienced by an older adult?
A. Older adults must learn to tolerate pain
B. Pain is a normal process of aging and is to be expected
C. Pain indicates a pathologic condition or injury and is not a normal process of aging
D. Older individuals perceive pain to a lesser degree than the younger individuals
73. A 4-year-old boy is brought to the emergency Department by his mother. She says he points to his stomach and says it hurts so bad. Which pain assessment tool would be the best choice when assessing the child's pain?
A. Descriptor scale
B. Numeric rating scale
C. Brief pain inventory
D. Faces pain scale revised (FPS-R)
74. A patient states that the pain medication is not working and rates his post-operative pain at a 10 on a 1-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?
C. Increased blood pressure and pulse
75. A 60 year old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the :
A. Affected extremity will eventually regain its function
B. Pain is felt at one site but originates from another location
C. patients pain will be Associated with nausea, pallor, and diaphoresis
D. Slightest touch, such as sleep brushing against her arm, causes severe and intense pain
76. The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the
A. Patients vital signs
B. Physical examination
C. Results of a computerized axial tomographic scan
D. Subjective report
77. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is bad this morning and rates it at in 8 on a 1-10 scale. What does the nurse suspect? The patient:
A. Is addicted to her pain medications and cannot obtain pain relief
B. Does not want to trouble the nursing staff with her complaints
C. Is not in pain but Ray said hi to receive pain medication
D. Has experienced chronic pain for years and has adapted to it
78. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the paint impulse do the peripheral or central nervous system?
79. When assessing the quality of a patient's pain, the nurse should ask which question?
A. When did the pain start?
B. Is the pain a stabbing pain?
C. Is it a sharp pain or a dull pain?
D. What does your pain feel like?
80. With assessing a patient's pain, the nurse knows that an example of visceral pain would be;
A. Hip fracture
C. Second-degree burns
D. Pain after a leg amputation
81. The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?
82. When assessing the intensity of a patient's pain, which question by the nurse is appropriate?
A. What makes your pain better or worse?
B. How much pain do you have now?
C. How does pain limit your activities?
D. What does your pain feel like?
83. A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
A. Completing the physical examination first and then giving pain medication
B. Telling the patient that the pain medication must wait until after the x-ray images are completed
C. Evaluating the full range of motion of the knee and then medicating for pain
D. Administering pain medication and then proceeding with the assessment.
84. The nurse knows that which statement is true regarding the pain experienced by infants?
A. Pain in infants can only be assessed by physiologic changes, such as increased heart rate
B. THE FPS-R can be used to assess pain in infants
C. A procedure that induces pain in adults will also induce pain in the infant
D. Infants feel pain less than do adults
85. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as
D. Deep somatic
86. During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain?
87. During an admission assessment of patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply
A. Ask the patient, do you have pain?
B. Assess the patients breathing independent of vocalization
C. Note whether the patient is calling out, groaning or crying
D. Have the pain rate pain on a 1-10 scale.
E. Observe the patients body language for pacing and agitation
88. An 85 year old man has come in for a physical examination, in the nurse notices that he uses a cane. when documenting general appearance, the nurse should document this information under the section that covers:
C. Mood and affect
D. Physical deformity
89. The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations?
90. After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to:
A. Empty the bladder
B. Completely disrobe
C. lie on the exam table
D. Walk around the room
91. During a complete health assessment, how would the nurse test the patient's hearing?
A. Observing how the patient participates in normal conversation
B. Using the whispered voice test
C. Using the Weber and Rinne tests
D. Testing with an audiometer
92. A patient states, whenever I open my mouth real wide, I feel this popping sensation in front of my ears. To further examine this, the nurse would;
A. Place the stethoscope over the temporomandibular joint and listen for bruits
B. Place the hands over his ears, and ask him to open his mouth really wide
C. Place on hand on his forehead and the other on his jaw, and ask him to open his mouth
D. Place a finger on his temporomandibular joint and ask him to open and close his mouth
93. The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves/
A. II, III, VI
B. II, IV, V
C. III, IV, V
D. III, IV, VI
94. A patient's uvula raises midline when she says ahh and she has a positive gag reflex. The nurse has just tested which cranial nerves?
A. IX and X
B. IX, and XII
C. X and XII
D. XI and XII
95. During an examination the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action?
96. A patient is unable to shrug her shoulders against the nurses resistant hands. What cranial nerve is involved with successful shoulder shrugging?
97. During an examination, a patient has successfully completed the finger to nose and rapid alternating movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's _____ function is intact.
98. When the nurse performs the confrontation test, the nurse has assessed:
A. Extraocular eye muscles (EOMs)
B. Pupils (PERRLA)
C. Near Vision
D. Visual fields
99. Which statement is true regarding the complete physical assessment?
A. The male genitalia should be examined in the supine position
B. The patient should be in the sitting position for the examination of the head and neck
C. The vital signs, height and weight should be obtained at the end of the examination
D. To promote consistency between patients, the examiner should not vary the order of the assessment
100. Which of these is included in an assessment of general appearance ?
C. Skin color
D. Vital signs
101. The nurse should wear gloves for which of these examinations?
A. Measuring vital signs
B. Palpation of the sinuses
C. Palpation of the mouth and tongue
D. Inspection of the eye with ophthalmoscope
102. The nurse should use which location for eliciting deep tendon reflexes?
103. During an inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicated which cranial nerve is intact?
104. During inspection of the posterior chest, the nurse should assess for:
A. Symmetric expansion
B. Symmetry of shoulders and muscles
C. Tactile fremitus
D. Diaphragmatic excursion
105. During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences:
106. A patient tells the nurse, sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath. When documenting this information, the nurse would note
B. Acute emphysema
C. Paroxysmal nocturnal dyspnea
D. Acute shortness of breath episode
107. During an examination of a patient, the nurse notices that she has several small, flat macules on the posterior portion of her thorax. The macules are less than 1 cm wide. Another name for these macules is
108. During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect:
B. Raynaud disease
C. Chronic arterial insufficiency
D. Chronic venous insufficiency
109. The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of;
B. Raynaud Disease
C. Chronic arterial insufficiency
D. Chronic venous insufficiency
110. The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates:
B. Raynaud disease
C. Arterial insufficiency
D. Venous insufficiency
111. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm
A. Inflamed liver
B. Perforated spleen
C. Perforated appendix
D. Enlarged gallbladder
112. The nurse will measure a patient's near vision with which tool?
A. Snellen eye chart with letters
B. Snellen E chart
C. Jaeger card
113. If the nurse records the results to the Hirschberg test, the nurse has:
A. Tested the patellar reflex
B. Assessed for appendicitis
C. Tested the corneal light reflex
D. Assessed for thrombophlebitis
114. During the examination of the patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as:
D. Torus palatinus
115. During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document:
116. After examination of the an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with
A. Cerebral palsy
B. Meningeal irritation
C. Lower motor neuron lesion
D. Upper motor neuron lesion
117. After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist papules in a cauliflower like patch around her introitus. This finding is most likely:
A. Urethral caruncle
B. Syphilitic chancre
C. Herpes simplex virus
D. Human papillomavirus
118. While recording in a patient's medical record, the nurse notices that a patients hematest results are positive. This finding means that there is(are):
A. Crystals in his urine
B. Parasites in his stool
C. Occult blood in his stool
D. Bacterial in his sputum
119. While examining a 48-year-old patients eyes, the nurse notices that he had to move the handheld vision screener further away from his face. The nurse would suspect:
120. A 5-year-old child is in the clinic for a checkup. The nurse would expect him to:
A. Need to be held on his mother's lap
B. Be able to sit on the examination table
C. Be able to stand on the floor for the examination
D. Be able to remain alone in the examination room
121. Which statement is true regarding the recording of data from the history and physical examination?
A. Use long, descriptive sentences to Document findings
B. Record the data as soon as possible after the interview and physical examination
C. If the information is not documented that it can be assumed that it was done as a standard of care
D. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient
122. When assessing the neonate, the nurse should test for hip stability with which method?
A. Eliciting the Moro reflex
B. Performing the Romberg test
C. Checking for the Ortolani sign
D. Assessing the stepping reflex
123. A female patient told the nurse that she has 4 children and has had 3 pregnancies how should be nurse document this ?
A. Gravida 3, para 4
B. Gravida 4, para 3
C. This information cannot be documented using the terms gravida and para
D. The patient seems to be confused about how many times she has been pregnant/
124. The nurse is documenting the assessment of an infant. During the abdominal assessment the nurse notice a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate:
A. Epigastric hernia
B. Pyloric obstruction
C. Hypoactive bowel sounds
D. Hyperactive bowel sounds
125. Which of these is most appropriate to perform on a 9 month old infant at a well child checkup?
A. Testing for the Ortolani sign
B. Assessment for stereognosis
C. Blood pressure measurement
D. Assessment for the presence of the startle reflex
126. The nurse is assessing an older adult's functional ability. which definition correctly describes one's functional abilities? Functional ability:
A. Is the measure of the expected changes of aging that one is experiencing?
B. Refers to the individual's motivation to live independently
C. Refers to the level of cognition present in the older person
D. Refers to one's ability to perform activities necessary to live in modern society
127. The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to:
A. Observe the patient's ability to perform the tasks
B. Ask the patients wife how he does when performing tasks
C. Review the medical record for information on the patient's abilities
D. Ask the patients physician for information on the patient's abilities
128. The nurse needs to assess a patient's ability to perform ADLs and should choose which tool for this assessment?
A. Direct assessment of functional abilities (DAFA)
B. Lawton Instrumental Activities of Daily Living (IADL) scale
C. Barthel Index
D. Older American Resources and Services Multidimensional Functional Assessment Questionnaire IADL (OMFAQ-IADL)
129. The nurse is preparing to use the Lawton IADL Instrument as part of an assessment. Which statement about the Lawton IADL assessment is true?
A. The nurse uses direct observation to implement this tool
B. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability
C. This instrument is not useful in the acute hospital setting
D. This tool is best used for those residing in an institutional setting
130. The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include:
A. Recreational activities
B. Meal preparation
C. Balancing the checkbook
D. Self-grooming activities
131. When using the various instruments to assess and older persons ADLs, the nurse needs to remember that a disadvantage of these instruments includes:
A. Reliability of the tools
B. Self or proxy reporting of functional activities
C. Lack of confidentiality during the assessment
D. Insufficient details concerning the deficiencies identified
132. A patient will be ready to be discharged from the hospital soon and the patient's family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this?
A. Get Up and Go Test
B. Performance ADLs
C. Physical Performance Test
D. Tinetti Gait and Balance Evaluation
133. The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support?
A. Local senior center
B. Patients Medicare check
C. Meals on Wheels meal delivery service
D. Patients neighbor, who visits with her daily
134. An 85-year-old man has been hospitalized after a fall at home, and his 86 year old wife is at his bedside. She told the nurse that she is his primary care giver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as:
B. Weight gain
D. Social phobias
135. During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status?
A. Geriatric Depression Scale, short form
B. Rapid Disability Rating Scale-2
D. Get Up and Go Test
136. An older patient has been admitted to the intensive care unit after falling at home. Within 8 hours, his condition has stabilized, and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time?
A. Lawton IADL instrument
B. Hospital Admission Risk Profile (HARP)
D. NEECHAM Confusion Scale
137. During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding Common environmental hazards?
A. Please slow toilet seats are safe because they are nearer to the ground in case of falls.
B. Do you have a relative or friend who can help install grab bars in your shower?
C. These small rugs are ideal for preventing you from sleeping on the hard floor
D. it would be safer to keep the writing low in this room to avoid glare in your eyes
138. When beginning to assess a person spirituality, Which question by the nurse would be most appropriate?
A. Do you believe in God?
B. How does your spirituality relate to your health care decisions?
C. What religious faith do you follow
D. Do you believe in the power of prayer?
139. The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain in the older adult is true?
A. Pain is inevitable with aging
B. Older adults with cognitive impairments feel less pain
C. Alleviating pain should be a priority over other aspects of the assessment
D. The assessment should take priority so that care decisions can be made
140. The nurse is assessing the abilities of an older adult. Which activities are considered IADLs. Select all that apply
A. Feeding oneself
B. Preparing a meal
C. Balancing a checkbook
F. Grocery Shopping