Test Bank for Health Assessment in Nursing, 7th North American Edition (Chapters 1-34)
Test Bank for Health Assessment in Nursing, 7th North American Edition (Chapters 1-34) offers detailed practice questions to sharpen your exam readiness. Download now!
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TEST BANK FOR HEALTH ASSESSMENT IN
NURSING KELLY TESTBANK- LATEST
VERSION||RATED A++||COMPLETE STUDY
GUIDE.
A nurse on a postsurgical unit is admitting a patient following the patient's cholecystectomy
(gall bladder removal). What is the overall purpose of assessment for this patient?
• Collecting accurate data
• Assisting the primary care provider
• Validating previous data
• Making clinical judgments
• A patient has presented to the emergency department (ED) with complaints of
abdominal pain. Which member of the care team would most likely be responsible for
collecting the subjective data on the patient during the initial comprehensive
assessment?
• Gastroenterologist
• ED nurse
• Admissions clerk
• Diagnostic technician
• The nurse has completed an initial assessment of a newly admitted patient and is
applying the nursing process to plan the patient's care. What principle should the nurse
apply when using the nursing process?
• Each step is independent of the others.
• It is ongoing and continuous.
• It is used primarily in acute care settings.
• It involves independent nursing actions.
• The nurse who provides care at an ambulatory clinic is preparing to meet a patient
and perform a comprehensive health assessment. Which of the following actions
should the nurse perform first?
• Review the patient's medical record.
• Obtain basic biographic data.
NURSING KELLY TESTBANK- LATEST
VERSION||RATED A++||COMPLETE STUDY
GUIDE.
A nurse on a postsurgical unit is admitting a patient following the patient's cholecystectomy
(gall bladder removal). What is the overall purpose of assessment for this patient?
• Collecting accurate data
• Assisting the primary care provider
• Validating previous data
• Making clinical judgments
• A patient has presented to the emergency department (ED) with complaints of
abdominal pain. Which member of the care team would most likely be responsible for
collecting the subjective data on the patient during the initial comprehensive
assessment?
• Gastroenterologist
• ED nurse
• Admissions clerk
• Diagnostic technician
• The nurse has completed an initial assessment of a newly admitted patient and is
applying the nursing process to plan the patient's care. What principle should the nurse
apply when using the nursing process?
• Each step is independent of the others.
• It is ongoing and continuous.
• It is used primarily in acute care settings.
• It involves independent nursing actions.
• The nurse who provides care at an ambulatory clinic is preparing to meet a patient
and perform a comprehensive health assessment. Which of the following actions
should the nurse perform first?
• Review the patient's medical record.
• Obtain basic biographic data.
TEST BANK FOR HEALTH ASSESSMENT IN
NURSING KELLY TESTBANK- LATEST
VERSION||RATED A++||COMPLETE STUDY
GUIDE.
A nurse on a postsurgical unit is admitting a patient following the patient's cholecystectomy
(gall bladder removal). What is the overall purpose of assessment for this patient?
• Collecting accurate data
• Assisting the primary care provider
• Validating previous data
• Making clinical judgments
• A patient has presented to the emergency department (ED) with complaints of
abdominal pain. Which member of the care team would most likely be responsible for
collecting the subjective data on the patient during the initial comprehensive
assessment?
• Gastroenterologist
• ED nurse
• Admissions clerk
• Diagnostic technician
• The nurse has completed an initial assessment of a newly admitted patient and is
applying the nursing process to plan the patient's care. What principle should the nurse
apply when using the nursing process?
• Each step is independent of the others.
• It is ongoing and continuous.
• It is used primarily in acute care settings.
• It involves independent nursing actions.
• The nurse who provides care at an ambulatory clinic is preparing to meet a patient
and perform a comprehensive health assessment. Which of the following actions
should the nurse perform first?
• Review the patient's medical record.
• Obtain basic biographic data.
NURSING KELLY TESTBANK- LATEST
VERSION||RATED A++||COMPLETE STUDY
GUIDE.
A nurse on a postsurgical unit is admitting a patient following the patient's cholecystectomy
(gall bladder removal). What is the overall purpose of assessment for this patient?
• Collecting accurate data
• Assisting the primary care provider
• Validating previous data
• Making clinical judgments
• A patient has presented to the emergency department (ED) with complaints of
abdominal pain. Which member of the care team would most likely be responsible for
collecting the subjective data on the patient during the initial comprehensive
assessment?
• Gastroenterologist
• ED nurse
• Admissions clerk
• Diagnostic technician
• The nurse has completed an initial assessment of a newly admitted patient and is
applying the nursing process to plan the patient's care. What principle should the nurse
apply when using the nursing process?
• Each step is independent of the others.
• It is ongoing and continuous.
• It is used primarily in acute care settings.
• It involves independent nursing actions.
• The nurse who provides care at an ambulatory clinic is preparing to meet a patient
and perform a comprehensive health assessment. Which of the following actions
should the nurse perform first?
• Review the patient's medical record.
• Obtain basic biographic data.
• Consult clinical resources explaining the patient's diagnosis.
• Validate information with the patient.
• Which of the following patient situations would the nurse interpret as requiring
an emergency assessment?
• A pediatric patient with severe sunburn
• A patient needing an employment physical
• A patient who overdosed on acetaminophen
• A distraught patient who wants a pregnancy test
• In response to a patient's query, the nurse is explaining the differences between the
physician's medical exam and the comprehensive health assessment performed by
the nurse. The nurse should describe the fact that the nursing assessment focuses on
which aspect of the patient's situation?
• Current physiologic status
• Effect of health on functional status
• Past medical history
• Motivation for adherence to treatment
• After teaching a group of students about the phases of the nursing process, the
instructor determines that the teaching was successful when the students identify
which phase as being foundational to all other phases?
• Assessment
• Planning
• Implementation
• Evaluation
• The nurse has completed the comprehensive health assessment of a patient who has
been admitted for the treatment of community-acquired pneumonia. Following the
completion of this assessment, the nurse periodically performs a partial assessment
primarily for which reason?
• Reassess previously detected problems
• Provide information for the patient's record
• Address areas previously omitted
• Determine the need for crisis intervention
• The nurse is working in an ambulatory care clinic that is located in a busy, inner-
city neighborhood. Which patient would the nurse determine to be in most need of
an emergency assessment?
• A 14-year-old girl who is crying because she thinks she is pregnant
• Validate information with the patient.
• Which of the following patient situations would the nurse interpret as requiring
an emergency assessment?
• A pediatric patient with severe sunburn
• A patient needing an employment physical
• A patient who overdosed on acetaminophen
• A distraught patient who wants a pregnancy test
• In response to a patient's query, the nurse is explaining the differences between the
physician's medical exam and the comprehensive health assessment performed by
the nurse. The nurse should describe the fact that the nursing assessment focuses on
which aspect of the patient's situation?
• Current physiologic status
• Effect of health on functional status
• Past medical history
• Motivation for adherence to treatment
• After teaching a group of students about the phases of the nursing process, the
instructor determines that the teaching was successful when the students identify
which phase as being foundational to all other phases?
• Assessment
• Planning
• Implementation
• Evaluation
• The nurse has completed the comprehensive health assessment of a patient who has
been admitted for the treatment of community-acquired pneumonia. Following the
completion of this assessment, the nurse periodically performs a partial assessment
primarily for which reason?
• Reassess previously detected problems
• Provide information for the patient's record
• Address areas previously omitted
• Determine the need for crisis intervention
• The nurse is working in an ambulatory care clinic that is located in a busy, inner-
city neighborhood. Which patient would the nurse determine to be in most need of
an emergency assessment?
• A 14-year-old girl who is crying because she thinks she is pregnant
• Consult clinical resources explaining the patient's diagnosis.
• Validate information with the patient.
• Which of the following patient situations would the nurse interpret as requiring
an emergency assessment?
• A pediatric patient with severe sunburn
• A patient needing an employment physical
• A patient who overdosed on acetaminophen
• A distraught patient who wants a pregnancy test
• In response to a patient's query, the nurse is explaining the differences between the
physician's medical exam and the comprehensive health assessment performed by
the nurse. The nurse should describe the fact that the nursing assessment focuses on
which aspect of the patient's situation?
• Current physiologic status
• Effect of health on functional status
• Past medical history
• Motivation for adherence to treatment
• After teaching a group of students about the phases of the nursing process, the
instructor determines that the teaching was successful when the students identify
which phase as being foundational to all other phases?
• Assessment
• Planning
• Implementation
• Evaluation
• The nurse has completed the comprehensive health assessment of a patient who has
been admitted for the treatment of community-acquired pneumonia. Following the
completion of this assessment, the nurse periodically performs a partial assessment
primarily for which reason?
• Reassess previously detected problems
• Provide information for the patient's record
• Address areas previously omitted
• Determine the need for crisis intervention
• The nurse is working in an ambulatory care clinic that is located in a busy, inner-
city neighborhood. Which patient would the nurse determine to be in most need of
an emergency assessment?
• A 14-year-old girl who is crying because she thinks she is pregnant
• Validate information with the patient.
• Which of the following patient situations would the nurse interpret as requiring
an emergency assessment?
• A pediatric patient with severe sunburn
• A patient needing an employment physical
• A patient who overdosed on acetaminophen
• A distraught patient who wants a pregnancy test
• In response to a patient's query, the nurse is explaining the differences between the
physician's medical exam and the comprehensive health assessment performed by
the nurse. The nurse should describe the fact that the nursing assessment focuses on
which aspect of the patient's situation?
• Current physiologic status
• Effect of health on functional status
• Past medical history
• Motivation for adherence to treatment
• After teaching a group of students about the phases of the nursing process, the
instructor determines that the teaching was successful when the students identify
which phase as being foundational to all other phases?
• Assessment
• Planning
• Implementation
• Evaluation
• The nurse has completed the comprehensive health assessment of a patient who has
been admitted for the treatment of community-acquired pneumonia. Following the
completion of this assessment, the nurse periodically performs a partial assessment
primarily for which reason?
• Reassess previously detected problems
• Provide information for the patient's record
• Address areas previously omitted
• Determine the need for crisis intervention
• The nurse is working in an ambulatory care clinic that is located in a busy, inner-
city neighborhood. Which patient would the nurse determine to be in most need of
an emergency assessment?
• A 14-year-old girl who is crying because she thinks she is pregnant
• A 45-year-old man with chest pain and diaphoresis for 1 hour
• A 3-year-old child with fever, rash, and sore throat
• A 20-year-old man with a 3-inch shallow laceration on his leg
• A nurse has completed gathering some basic data about a patient who has multiple
health problems that stem from heavy alcohol use. The nurse has then reflected on her
personal feelings about the patient and his circumstances. The nurse does this
primarily to accomplish which of the following?
• Determine if pertinent data has been omitted
• Identify the need for referral
• Avoid biases and judgments
• Construct a plan of care
• The nurse is collecting data from a patient who has recently been diagnosed with type
1 diabetes and who will begin an educational program. The nurse is collecting
subjective and objective data. Which of the following would the nurse categorize as
objective data?
• Family history
• Occupation
• Appearance
• History of present health concern
• An older adult patient has been admitted to the hospital with failure to thrive
resulting from complications of diabetes. Which of the following would the nurse
implement in response to a collaborative problem?
• Encourage the patient to increase oral fluid intake.
• Provide the patient with a bedtime protein snack.
• Assist the patient with personal hygiene.
• Measure the patient's blood glucose four times daily.
• The nurse at a busy primary care clinic is analyzing the data obtained from the
following patients. For which patients would the nurse most likely expect to
facilitate a referral?
• An 80-year-old patient who lives with her daughter
• A 50-year-old patient newly diagnosed with diabetes
• An adult presenting for an influenza vaccination
• A teenager seeking information about contraception
• A 3-year-old child with fever, rash, and sore throat
• A 20-year-old man with a 3-inch shallow laceration on his leg
• A nurse has completed gathering some basic data about a patient who has multiple
health problems that stem from heavy alcohol use. The nurse has then reflected on her
personal feelings about the patient and his circumstances. The nurse does this
primarily to accomplish which of the following?
• Determine if pertinent data has been omitted
• Identify the need for referral
• Avoid biases and judgments
• Construct a plan of care
• The nurse is collecting data from a patient who has recently been diagnosed with type
1 diabetes and who will begin an educational program. The nurse is collecting
subjective and objective data. Which of the following would the nurse categorize as
objective data?
• Family history
• Occupation
• Appearance
• History of present health concern
• An older adult patient has been admitted to the hospital with failure to thrive
resulting from complications of diabetes. Which of the following would the nurse
implement in response to a collaborative problem?
• Encourage the patient to increase oral fluid intake.
• Provide the patient with a bedtime protein snack.
• Assist the patient with personal hygiene.
• Measure the patient's blood glucose four times daily.
• The nurse at a busy primary care clinic is analyzing the data obtained from the
following patients. For which patients would the nurse most likely expect to
facilitate a referral?
• An 80-year-old patient who lives with her daughter
• A 50-year-old patient newly diagnosed with diabetes
• An adult presenting for an influenza vaccination
• A teenager seeking information about contraception
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• An instructor is reviewing the evolution of the nurse's role in health assessment. The
instructor determines that the teaching was successful when the students identify
which of the following as the major method used by nurses early in the history of the
profession?
• Natural senses
• Biomedical knowledge
• Simple technology
• Critical pathways
• When describing the expansion of the depth and scope of nursing assessment over
the past several decades, which of the following would the nurse identify as being
the primary force?
• Documentation
• Informatics
• Diversification
• Technology
• A group of nurses are reviewing information about the potential opportunities for
nurses who have advanced assessment skills. When discussing phenomena that have
contributed to these increased opportunities, what should the nurses identify?
• Expansion of health care networks
• Decrease in patient participation in care
• The shrinking cost of medical care
• Public mistrust of physicians
• A nurse has documented the findings of a comprehensive assessment of a new
patient. What is the primary rationale that the nurse should identify for accurate and
thorough documentation?
• Guaranteeing a continual assessment process
• Identifying abnormal data
• Assuring valid conclusions from analyzed data
• Allowing for drawing inferences and identifying problems
• A nurse has received a report on a patient who will soon be admitted to the medical
unit from the emergency department. When preparing for the assessment phase of
the nursing process, which of the following should the nurse do first?
• Collect objective data.
• Validate important data.
• Collect subjective data.
• Document the data.
instructor determines that the teaching was successful when the students identify
which of the following as the major method used by nurses early in the history of the
profession?
• Natural senses
• Biomedical knowledge
• Simple technology
• Critical pathways
• When describing the expansion of the depth and scope of nursing assessment over
the past several decades, which of the following would the nurse identify as being
the primary force?
• Documentation
• Informatics
• Diversification
• Technology
• A group of nurses are reviewing information about the potential opportunities for
nurses who have advanced assessment skills. When discussing phenomena that have
contributed to these increased opportunities, what should the nurses identify?
• Expansion of health care networks
• Decrease in patient participation in care
• The shrinking cost of medical care
• Public mistrust of physicians
• A nurse has documented the findings of a comprehensive assessment of a new
patient. What is the primary rationale that the nurse should identify for accurate and
thorough documentation?
• Guaranteeing a continual assessment process
• Identifying abnormal data
• Assuring valid conclusions from analyzed data
• Allowing for drawing inferences and identifying problems
• A nurse has received a report on a patient who will soon be admitted to the medical
unit from the emergency department. When preparing for the assessment phase of
the nursing process, which of the following should the nurse do first?
• Collect objective data.
• Validate important data.
• Collect subjective data.
• Document the data.
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• A community health nurse is assessing an older adult patient in the patient's home.
When the nurse is gathering subjective data, which of the following would the nurse
identify?
• The patient's feelings of happiness
• The patient's posture
• The patient's affect
• The patient's behavior
• A nurse on the hospital's subacute medical unit is planning to perform a patient's
focused assessment. Which of the following statements should inform the nurse's
practice?
• The focused assessment should be done before the physical exam.
• The focused assessment replaces the comprehensive database.
• The focused assessment addresses a particular patient problem.
• The focused assessment is done after gathering subjective data.
• The nurse is reviewing a patient's health history and the results of the most recent
physical examination. Which of the following data would the nurse identify as
being subjective? Select all that apply.
• ìI feel so tired sometimes.î
• Weight: 145 lbs
• Lungs clear to auscultation
• patient complains of a headache
• ìMy father died of a heart attack.î
• Pupils equal, round, and reactive to light
• The nurse has been applying the nursing process in the care of an adult patient
who is being treated for acute pancreatitis. Place the nurse's actions in their proper
sequence from first to last.
• Identifying outcomes
• Determining patient's nursing problem
• Collecting information about the patient
• Determining outcome achievement
• Carrying out interventions
C,B,A,E,D
When the nurse is gathering subjective data, which of the following would the nurse
identify?
• The patient's feelings of happiness
• The patient's posture
• The patient's affect
• The patient's behavior
• A nurse on the hospital's subacute medical unit is planning to perform a patient's
focused assessment. Which of the following statements should inform the nurse's
practice?
• The focused assessment should be done before the physical exam.
• The focused assessment replaces the comprehensive database.
• The focused assessment addresses a particular patient problem.
• The focused assessment is done after gathering subjective data.
• The nurse is reviewing a patient's health history and the results of the most recent
physical examination. Which of the following data would the nurse identify as
being subjective? Select all that apply.
• ìI feel so tired sometimes.î
• Weight: 145 lbs
• Lungs clear to auscultation
• patient complains of a headache
• ìMy father died of a heart attack.î
• Pupils equal, round, and reactive to light
• The nurse has been applying the nursing process in the care of an adult patient
who is being treated for acute pancreatitis. Place the nurse's actions in their proper
sequence from first to last.
• Identifying outcomes
• Determining patient's nursing problem
• Collecting information about the patient
• Determining outcome achievement
• Carrying out interventions
C,B,A,E,D
Loading page 6...
• A nurse is completing an assessment that will involve gathering subjective and
objective data. Which of the following assessment techniques will best allow the nurse
to collect objective data?
• Inspection
• Therapeutic communication
• Interviewing
• Active listening
• The nurse is performing a health assessment on a community-dwelling patient
who is recovering from hip replacement surgery. Which of the following actions
should the nurse prioritize during assessment?
• Focus the assessment on the patient as a member of her age group.
• Interpret the information about the patient in context.
• Corroborate the patient's statements with trusted sources.
• Gather information from a variety of sources.
• A patient comes to the health care provider's office for a visit. The patient has been
seen in this office on occasion for the past 5 years and arrives today complaining of a
fever and sore throat. Which type of assessment would the nurse most likely perform?
• Comprehensive assessment
• Ongoing assessment
• Focused assessment
• Emergency assessment
• A nurse has assessed a patient who was admitted to the medical unit to treat acute
complications of type 1 diabetes. During the assessment, the patient admitted that
his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the
nurse best respond to this assessment finding?
• Identify a nursing diagnosis of Ineffective Health Maintenance.
• Identify a collaborative problem that should involve the occupational therapist.
• Make a referral to the unit's social work department.
• Reassess the patient's blood glucose level.
• The nurse is utilizing the Health Belief Model in the care of a patient whose type 1
diabetes is inadequately controlled. When implementing this model, the nurse
should begin by assessing which of the following?
• The patient's motivation for change
• The patient's medical comorbidities
• The patient's learning style
• The patient's prognosis for recovery
objective data. Which of the following assessment techniques will best allow the nurse
to collect objective data?
• Inspection
• Therapeutic communication
• Interviewing
• Active listening
• The nurse is performing a health assessment on a community-dwelling patient
who is recovering from hip replacement surgery. Which of the following actions
should the nurse prioritize during assessment?
• Focus the assessment on the patient as a member of her age group.
• Interpret the information about the patient in context.
• Corroborate the patient's statements with trusted sources.
• Gather information from a variety of sources.
• A patient comes to the health care provider's office for a visit. The patient has been
seen in this office on occasion for the past 5 years and arrives today complaining of a
fever and sore throat. Which type of assessment would the nurse most likely perform?
• Comprehensive assessment
• Ongoing assessment
• Focused assessment
• Emergency assessment
• A nurse has assessed a patient who was admitted to the medical unit to treat acute
complications of type 1 diabetes. During the assessment, the patient admitted that
his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the
nurse best respond to this assessment finding?
• Identify a nursing diagnosis of Ineffective Health Maintenance.
• Identify a collaborative problem that should involve the occupational therapist.
• Make a referral to the unit's social work department.
• Reassess the patient's blood glucose level.
• The nurse is utilizing the Health Belief Model in the care of a patient whose type 1
diabetes is inadequately controlled. When implementing this model, the nurse
should begin by assessing which of the following?
• The patient's motivation for change
• The patient's medical comorbidities
• The patient's learning style
• The patient's prognosis for recovery
Loading page 7...
• A nurse will complete an initial comprehensive assessment of a 60-year-old patient
who is new to the clinic. What goal should the nurse identify for this type of
assessment?
• Identify the most appropriate forms of medical intervention for the patient.
• Determine the most likely prognosis for the patient's health problem.
• Identify the status of the patient's airway, breathing, and circulation.
• Establish a baseline for the comparison of future health changes.
• A nurse who provides care in a hospital setting is creating a plan of nursing care for
a patient who has a diagnosis of chronic renal failure. The nurse's plan specifies
frequent ongoing assessments. The frequency of these nursing assessments should
be primarily determined by what variable?
• The patient's age
• The unit's protocols
• The patient's acuity
• The nurse's potential for liability
• A patient who is new to the facility has a recent history of chronic pain that is
attributed to fibromyalgia. The nurse has reviewed the available health records and
suspects that pain management will be a major focus of nursing care. How can the
nurse best validate this assumption?
• Review the patient's medication administration record for analgesic use.
• Ask the patient about the most recent experiences of pain.
• Meet with the patient's spouse and daughter to discuss the patient's pain.
• Collaborate with the physician who is treating the patient.
Answer Key
• D
• B
• B
• A
• C
• B
• A
• A
• B
• C
• C
• D
• B
who is new to the clinic. What goal should the nurse identify for this type of
assessment?
• Identify the most appropriate forms of medical intervention for the patient.
• Determine the most likely prognosis for the patient's health problem.
• Identify the status of the patient's airway, breathing, and circulation.
• Establish a baseline for the comparison of future health changes.
• A nurse who provides care in a hospital setting is creating a plan of nursing care for
a patient who has a diagnosis of chronic renal failure. The nurse's plan specifies
frequent ongoing assessments. The frequency of these nursing assessments should
be primarily determined by what variable?
• The patient's age
• The unit's protocols
• The patient's acuity
• The nurse's potential for liability
• A patient who is new to the facility has a recent history of chronic pain that is
attributed to fibromyalgia. The nurse has reviewed the available health records and
suspects that pain management will be a major focus of nursing care. How can the
nurse best validate this assumption?
• Review the patient's medication administration record for analgesic use.
• Ask the patient about the most recent experiences of pain.
• Meet with the patient's spouse and daughter to discuss the patient's pain.
• Collaborate with the physician who is treating the patient.
Answer Key
• D
• B
• B
• A
• C
• B
• A
• A
• B
• C
• C
• D
• B
Loading page 8...
• A
• D
• A
• C
• C
• A
• C
• A, D, E
• C, B, A, E, D
• A
• B
• C
• A
• A
• D
• C
• B
• A nurse is preparing to assess a patient who is new to the clinic. When beginning
the collection of the patient database, which of the following actions should the
nurse prioritize?
• Establishing a trusting relationship
• Determining the patient's strengths
• Identifying potential health problems
• Making clinical inferences
• A nurse is interpreting and validating information from an older adult patient who
has been experiencing a functional decline. The nurse is in which phase of the
interview?
• Introductory
• Working
• Summary
• Closing
• A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy,
and the nurse is collecting subjective data prior to surgery. Which statement by the
nurse could be construed as judgmental?
• “How often do your adult children typically visit you?”
• “Your husband's death must have been very difficult for you.”
• “You must quit smoking because it affects others, not only you.”
• D
• A
• C
• C
• A
• C
• A, D, E
• C, B, A, E, D
• A
• B
• C
• A
• A
• D
• C
• B
• A nurse is preparing to assess a patient who is new to the clinic. When beginning
the collection of the patient database, which of the following actions should the
nurse prioritize?
• Establishing a trusting relationship
• Determining the patient's strengths
• Identifying potential health problems
• Making clinical inferences
• A nurse is interpreting and validating information from an older adult patient who
has been experiencing a functional decline. The nurse is in which phase of the
interview?
• Introductory
• Working
• Summary
• Closing
• A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy,
and the nurse is collecting subjective data prior to surgery. Which statement by the
nurse could be construed as judgmental?
• “How often do your adult children typically visit you?”
• “Your husband's death must have been very difficult for you.”
• “You must quit smoking because it affects others, not only you.”
Loading page 9...
• “How would you describe your feelings about getting older?”
• A nurse is interviewing a 22-year-old patient of the campus medical clinic. Which
nonverbal behavior should the nurse adopt to best facilitate communication during
this phase of assessment?
• Standing while the patient is seated
• Using a moderate amount of eye contact
• Sitting across the room from the patient
• Minimizing facial expressions
• A nurse is providing feedback to a colleague after observing the colleague's interview
of a newly admitted patient. Which of the following would the nurse identify as an
example of a closed-ended question or statement?
• “Tell me about your relationship with your children?”
• “Tell me what you eat in a normal day?”
• “Are you allergic to any medications?”
• “What is your typical day like?”
• A patient has presented to the emergency department and is having difficulty
describing her vague sensation of physical discomfort and unease. How can the
nurse best elicit meaningful assessment data about the nature of the patient's
complaint?
• Ignore the complaint for now and return to it later in the assessment.
• Provide a laundry list of descriptive words.
• Restate the question using simpler terms.
• Wait in silence until the patient can determine the correct words.
• A nurse is eliciting a patient's health history and the patient asks, “Can I take the
herb ginkgo biloba with my other medications?” What action would be best if the
nurse is unsure of the answer?
• Promise to find out the information for the patient.
• Change the subject and return to this topic later.
• Teach the patient to only take prescribed medications.
• Encourage the patient to ask the pharmacist or primary care provider.
• The nurse is preparing to assess the mental status of a 90-year-old patient who is
being admitted to the hospital from a long-term care facility. Which of the
following should the nurse assess first?
• The patient's sensory abilities
• The patient's general intelligence
• A nurse is interviewing a 22-year-old patient of the campus medical clinic. Which
nonverbal behavior should the nurse adopt to best facilitate communication during
this phase of assessment?
• Standing while the patient is seated
• Using a moderate amount of eye contact
• Sitting across the room from the patient
• Minimizing facial expressions
• A nurse is providing feedback to a colleague after observing the colleague's interview
of a newly admitted patient. Which of the following would the nurse identify as an
example of a closed-ended question or statement?
• “Tell me about your relationship with your children?”
• “Tell me what you eat in a normal day?”
• “Are you allergic to any medications?”
• “What is your typical day like?”
• A patient has presented to the emergency department and is having difficulty
describing her vague sensation of physical discomfort and unease. How can the
nurse best elicit meaningful assessment data about the nature of the patient's
complaint?
• Ignore the complaint for now and return to it later in the assessment.
• Provide a laundry list of descriptive words.
• Restate the question using simpler terms.
• Wait in silence until the patient can determine the correct words.
• A nurse is eliciting a patient's health history and the patient asks, “Can I take the
herb ginkgo biloba with my other medications?” What action would be best if the
nurse is unsure of the answer?
• Promise to find out the information for the patient.
• Change the subject and return to this topic later.
• Teach the patient to only take prescribed medications.
• Encourage the patient to ask the pharmacist or primary care provider.
• The nurse is preparing to assess the mental status of a 90-year-old patient who is
being admitted to the hospital from a long-term care facility. Which of the
following should the nurse assess first?
• The patient's sensory abilities
• The patient's general intelligence
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• The presence of any phobias
• The patient's judgment and insight
• A nurse provides care in a rural hospital that serves a community that has few
minority residents. When interviewing a patient from a minority culture, the nurse has
enlisted the assistance of a “culture broker.” How can this individual best facilitate
the patient's care?
• By interpreting the patient's language and culture
• By evaluating the patient's culturally based health practices
• By teaching the patient about health care
• By making the patient feel comfortable and safe
• Upon entering an exam room, the patient states, “Well! I was getting ready to leave.
My schedule is very busy and I don't have time to waste waiting until you have the
time to see me!” Which response by the nurse would be most appropriate?
• “Our schedule is very busy also. We got to you as soon as we could.”
• “No one is forcing you to be here, and you are free to leave at any time.”
• “Would you like to report your complaints to someone with power?”
• “You're certainly justified in being upset, but I am ready to begin your exam now.”
• A nurse has admitted a patient to the medical unit and is describing the purpose for
obtaining a comprehensive health history. Which of the following purposes should
the nurse describe?
• “This helps us to complete your health record accurately.”
• “This helps us to establish a trusting interpersonal relationship.”
• “This helps us to evaluate the seriousness of your risk factors for disease.”
• “This helps us have an appropriate focus for the physical examination.”
• A clinic nurse has reviewed a new patient's available health record and will now
begin taking the patient's health history. Which of the following questions should the
nurse ask first when obtaining the health history?
• “Do you have adequate health insurance coverage?”
• “Are you generally fairly healthy?”
• “What is your major health concern at this time?”
• “Did you bring all your medications with you?”
• A patient has presented for care with complaints of persistent lower back pain.
When using the mnemonic COLDSPA, which question should the nurse use to
evaluate the “P”?
• “What makes it worse?”
• The patient's judgment and insight
• A nurse provides care in a rural hospital that serves a community that has few
minority residents. When interviewing a patient from a minority culture, the nurse has
enlisted the assistance of a “culture broker.” How can this individual best facilitate
the patient's care?
• By interpreting the patient's language and culture
• By evaluating the patient's culturally based health practices
• By teaching the patient about health care
• By making the patient feel comfortable and safe
• Upon entering an exam room, the patient states, “Well! I was getting ready to leave.
My schedule is very busy and I don't have time to waste waiting until you have the
time to see me!” Which response by the nurse would be most appropriate?
• “Our schedule is very busy also. We got to you as soon as we could.”
• “No one is forcing you to be here, and you are free to leave at any time.”
• “Would you like to report your complaints to someone with power?”
• “You're certainly justified in being upset, but I am ready to begin your exam now.”
• A nurse has admitted a patient to the medical unit and is describing the purpose for
obtaining a comprehensive health history. Which of the following purposes should
the nurse describe?
• “This helps us to complete your health record accurately.”
• “This helps us to establish a trusting interpersonal relationship.”
• “This helps us to evaluate the seriousness of your risk factors for disease.”
• “This helps us have an appropriate focus for the physical examination.”
• A clinic nurse has reviewed a new patient's available health record and will now
begin taking the patient's health history. Which of the following questions should the
nurse ask first when obtaining the health history?
• “Do you have adequate health insurance coverage?”
• “Are you generally fairly healthy?”
• “What is your major health concern at this time?”
• “Did you bring all your medications with you?”
• A patient has presented for care with complaints of persistent lower back pain.
When using the mnemonic COLDSPA, which question should the nurse use to
evaluate the “P”?
• “What makes it worse?”
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• “When did it start?”
• “How does it feel?”
• “How would you rate your pain?”
• A medical nurse has completed the review of systems component of the patient's
health history. Which assessment finding should the nurse document under the
review of systems?
• “High school diploma plus 2 years of college”
• “Caregiver reliable source of information”
• “Menarche at age 13”
• “Lungs clear to auscultation bilaterally”
• A patient has been admitted following an unexplained weight loss of 15 pounds over
the past 3 months. How should the nurse best assess the subjective component of the
patient's nutritional status?
• Ask the patient to explain MyPlate.
• Obtain a 24-hour diet recall.
• Ask about the contents of one typical meal.
• Elicit the patient's favorite foods.
• A patient's elevated body mass index (BMI) has prompted the nurse to assess the
patient's activity and exercise level. Which statement would indicate to the nurse that
the patient is getting the recommended amount of exercise?
• “I walk briskly on the treadmill once or twice a week.”
• “I play basketball with a team every Friday night without fail.”
• “I go to a step class for an hour three times a week.”
• “I swim for at least half an hour each Saturday morning.”
• During an assessment, the nurse determines that a patient sees more than one
primary care provider and has obtained prescriptions from each provider. Which
method would be most appropriate to determine a patient's current medication
regimen?
• Ask the patient to identify which medications taken every day.
• Ask the patient to bring all the medications and supplements to an interview.
• Ask the caregiver whether the patient is taking prescribed medications.
• Ask the patient about the use of any over-the-counter medications.
• The nurse is preparing to assess an adult woman's activities related to health
promotion and maintenance. Which question should the nurse ask to obtain the most
objective and thorough assessment data?
• “How does it feel?”
• “How would you rate your pain?”
• A medical nurse has completed the review of systems component of the patient's
health history. Which assessment finding should the nurse document under the
review of systems?
• “High school diploma plus 2 years of college”
• “Caregiver reliable source of information”
• “Menarche at age 13”
• “Lungs clear to auscultation bilaterally”
• A patient has been admitted following an unexplained weight loss of 15 pounds over
the past 3 months. How should the nurse best assess the subjective component of the
patient's nutritional status?
• Ask the patient to explain MyPlate.
• Obtain a 24-hour diet recall.
• Ask about the contents of one typical meal.
• Elicit the patient's favorite foods.
• A patient's elevated body mass index (BMI) has prompted the nurse to assess the
patient's activity and exercise level. Which statement would indicate to the nurse that
the patient is getting the recommended amount of exercise?
• “I walk briskly on the treadmill once or twice a week.”
• “I play basketball with a team every Friday night without fail.”
• “I go to a step class for an hour three times a week.”
• “I swim for at least half an hour each Saturday morning.”
• During an assessment, the nurse determines that a patient sees more than one
primary care provider and has obtained prescriptions from each provider. Which
method would be most appropriate to determine a patient's current medication
regimen?
• Ask the patient to identify which medications taken every day.
• Ask the patient to bring all the medications and supplements to an interview.
• Ask the caregiver whether the patient is taking prescribed medications.
• Ask the patient about the use of any over-the-counter medications.
• The nurse is preparing to assess an adult woman's activities related to health
promotion and maintenance. Which question should the nurse ask to obtain the most
objective and thorough assessment data?
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• “Do you always wear your seatbelt when driving?”
• “How much beer, wine, or alcohol do you drink?”
• “Do you use condoms with each sexual encounter?”
• “Could you describe how you perform self-breast exams?”
• A nurse is creating a genogram of a patient's family health history. The nurse should
use which of the following symbols to denote the patient's female relatives?
• Circle
• Square
• Triangle
• Rectangle
• A patient has just been admitted to the postsurgical unit from postanesthetic recovery,
and the nurse is in the introductory phase of the patient interview. Which of the
following activities should the nurse perform first?
• Collaborate with the patient to identify problems.
• Explain the purpose of the interview.
• Determine the patient's vital signs.
• Obtain family health history data.
• During the interview, the patient states, “Is today the 12th? My wife died 2 months
ago today.” Which of the following responses would be most appropriate?
• “What was the cause of your wife's death?”
• “How does that make you feel right now?”
• “You probably must be sad.”
• “Are you feeling sad, depressed, angry, or upset?”
• The nurse is using the mnemonic “COLDSPA” to assess a patient's complaint of
lower abdominal pain. The nurse asks the patient to rate the pain on a scale of 0 to
10. The nurse is assessing which aspect of the complaint?
• Character
• Onset
• Severity
• Pattern
• The nurse is obtaining information about a patient's past health history. Which
patient statement would best reflect this component of assessment?
• “My mom's still alive, but my dad died 10 years ago of heart failure.”
• “I have a brother with leukemia and a sister with hypertension.”
• “How much beer, wine, or alcohol do you drink?”
• “Do you use condoms with each sexual encounter?”
• “Could you describe how you perform self-breast exams?”
• A nurse is creating a genogram of a patient's family health history. The nurse should
use which of the following symbols to denote the patient's female relatives?
• Circle
• Square
• Triangle
• Rectangle
• A patient has just been admitted to the postsurgical unit from postanesthetic recovery,
and the nurse is in the introductory phase of the patient interview. Which of the
following activities should the nurse perform first?
• Collaborate with the patient to identify problems.
• Explain the purpose of the interview.
• Determine the patient's vital signs.
• Obtain family health history data.
• During the interview, the patient states, “Is today the 12th? My wife died 2 months
ago today.” Which of the following responses would be most appropriate?
• “What was the cause of your wife's death?”
• “How does that make you feel right now?”
• “You probably must be sad.”
• “Are you feeling sad, depressed, angry, or upset?”
• The nurse is using the mnemonic “COLDSPA” to assess a patient's complaint of
lower abdominal pain. The nurse asks the patient to rate the pain on a scale of 0 to
10. The nurse is assessing which aspect of the complaint?
• Character
• Onset
• Severity
• Pattern
• The nurse is obtaining information about a patient's past health history. Which
patient statement would best reflect this component of assessment?
• “My mom's still alive, but my dad died 10 years ago of heart failure.”
• “I have a brother with leukemia and a sister with hypertension.”
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• “I had surgery 5 years ago to repair an inguinal hernia.”
• “I have been having some pain when I urinate for the last several days.”
• A nurse is teaching a recent nursing graduate about the significance of verbal and
nonverbal communication during patient care. The new graduate demonstrates an
understanding of these techniques by citing what example of verbal
communication?
• Maintaining an open attitude
• Using silence appropriately
• Providing a laundry list of descriptors when needed
• Maintaining an open and encouraging facial expression
• The admission of a new resident to a long-term care facility has necessitated a
thorough health history. Place the following focuses in the correct sequence in which
the nurse should perform them, beginning with the section obtained first.
• Family health history
• Reason for seeking care
• Biographic data
• Review of body systems
• History of present concern
• Past health history
C,B,E,F,A,D
• The nurse is completing a review of systems for a patient. Which of the following
information would the nurse document related to the patient's musculoskeletal
system? Select all that apply.
• Joint stiffness
• Rhinorrhea
• Shortness of breath
• Chest pain
• Muscle strength
• Knee swelling
• The nurse is completing an assessment of a 50-year-old female patient who has
sought care for recurrent migraines that have not responded to treatment. Following
the review of systems, how should the nurse best document unremarkable results of
the subjective portion of the gastrointestinal assessment?
• “patient's gastrointestinal health is within reference ranges for age.”
• “I have been having some pain when I urinate for the last several days.”
• A nurse is teaching a recent nursing graduate about the significance of verbal and
nonverbal communication during patient care. The new graduate demonstrates an
understanding of these techniques by citing what example of verbal
communication?
• Maintaining an open attitude
• Using silence appropriately
• Providing a laundry list of descriptors when needed
• Maintaining an open and encouraging facial expression
• The admission of a new resident to a long-term care facility has necessitated a
thorough health history. Place the following focuses in the correct sequence in which
the nurse should perform them, beginning with the section obtained first.
• Family health history
• Reason for seeking care
• Biographic data
• Review of body systems
• History of present concern
• Past health history
C,B,E,F,A,D
• The nurse is completing a review of systems for a patient. Which of the following
information would the nurse document related to the patient's musculoskeletal
system? Select all that apply.
• Joint stiffness
• Rhinorrhea
• Shortness of breath
• Chest pain
• Muscle strength
• Knee swelling
• The nurse is completing an assessment of a 50-year-old female patient who has
sought care for recurrent migraines that have not responded to treatment. Following
the review of systems, how should the nurse best document unremarkable results of
the subjective portion of the gastrointestinal assessment?
• “patient's gastrointestinal health is within reference ranges for age.”
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• “patient denies GI signs and symptoms.”
• “Gastrointestinal problems are absent.”
• “patient denies recent constipation, diarrhea, bowel incontinence, or abdominal
pain.”
• A 60-year-old woman with a bunion will undergo surgery later today. The patient
tells the nurse in the surgical daycare admitting department, “I'm sure I've been
asked these questions before. Can't we just focus on my foot and not all these other
topics?” How should the nurse best explain the rationale for obtaining a health
history?
• “In general, it's necessary for us to gather as much information about each patient
as possible.”
• “We want to make sure your nursing care matches your needs as closely as
possible.”
• “The care team needs to cross-reference your diagnostic testing with
the information that I'm asking you about.”
• “We don't want to make the mistake of focusing solely on the medical problem
that brought you here.”
• During the nurse's assessment of the patient's exercise and activity habits, the patient
laughs and then states, “Unless you're including channel surfing, I don't really do
much of anything.” How should the nurse best follow up this patient's statement?
• Briefly describe some of the potential benefits of regular exercise.
• Ask the patient if he understands the risk factors for heart disease and diabetes.
• Explain to the patient that he should be performing aerobic exercise for 20 to
30 minutes at least three times a week.
• Document the nursing diagnosis of Risk for Activity Intolerance related
to sedentary lifestyle.
• A nurse is obtaining subjective data from an adult patient who is new to the clinic.
The nurse has asked the patient, “Where do you usually turn for help in a time of
crisis?” What domain is this nurse assessing?
• The patient's family relationships
• The patient's current level of social and relational stability
• The patient's critical thinking and problem-solving abilities
• The patient's stress management and coping strategies
Answer Key
• A
• B
• “Gastrointestinal problems are absent.”
• “patient denies recent constipation, diarrhea, bowel incontinence, or abdominal
pain.”
• A 60-year-old woman with a bunion will undergo surgery later today. The patient
tells the nurse in the surgical daycare admitting department, “I'm sure I've been
asked these questions before. Can't we just focus on my foot and not all these other
topics?” How should the nurse best explain the rationale for obtaining a health
history?
• “In general, it's necessary for us to gather as much information about each patient
as possible.”
• “We want to make sure your nursing care matches your needs as closely as
possible.”
• “The care team needs to cross-reference your diagnostic testing with
the information that I'm asking you about.”
• “We don't want to make the mistake of focusing solely on the medical problem
that brought you here.”
• During the nurse's assessment of the patient's exercise and activity habits, the patient
laughs and then states, “Unless you're including channel surfing, I don't really do
much of anything.” How should the nurse best follow up this patient's statement?
• Briefly describe some of the potential benefits of regular exercise.
• Ask the patient if he understands the risk factors for heart disease and diabetes.
• Explain to the patient that he should be performing aerobic exercise for 20 to
30 minutes at least three times a week.
• Document the nursing diagnosis of Risk for Activity Intolerance related
to sedentary lifestyle.
• A nurse is obtaining subjective data from an adult patient who is new to the clinic.
The nurse has asked the patient, “Where do you usually turn for help in a time of
crisis?” What domain is this nurse assessing?
• The patient's family relationships
• The patient's current level of social and relational stability
• The patient's critical thinking and problem-solving abilities
• The patient's stress management and coping strategies
Answer Key
• A
• B
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• C
• B
• C
• B
• A
• A
• A
• D
• D
• C
• A
• C
• B
• C
• B
• D
• A
• B
• B
• C
• C
• C
• C, B, E, F, A, D
• A, E, F
• D
• B
• A
• D
• A patient has presented to the clinic for the treatment of an ovarian cyst. Which of
the following would be most important for the nurse to do immediately before
performing this woman's physical exam?
• Explain the purpose of the interview to the patient.
• Construct the patient's family genogram.
• Establish the patient's reliability as historian.
• Collect necessary equipment essential to the exam.
• A young adult patient has come to the clinic for her scheduled Pap (Papanicolaou)
test and pelvic examination. The nurse is implementing actions to help reduce a
patient's anxiety during the physical exam. Which of the following would be most
appropriate?
• B
• C
• B
• A
• A
• A
• D
• D
• C
• A
• C
• B
• C
• B
• D
• A
• B
• B
• C
• C
• C
• C, B, E, F, A, D
• A, E, F
• D
• B
• A
• D
• A patient has presented to the clinic for the treatment of an ovarian cyst. Which of
the following would be most important for the nurse to do immediately before
performing this woman's physical exam?
• Explain the purpose of the interview to the patient.
• Construct the patient's family genogram.
• Establish the patient's reliability as historian.
• Collect necessary equipment essential to the exam.
• A young adult patient has come to the clinic for her scheduled Pap (Papanicolaou)
test and pelvic examination. The nurse is implementing actions to help reduce a
patient's anxiety during the physical exam. Which of the following would be most
appropriate?
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• Ensuring patient's privacy by providing an examination gown
• Providing a comfortable, warm room temperature
• Arranging exam equipment on a bedside tray table
• Explaining why standard precautions are being used
• A nurse is admitting a new patient to the subacute medical unit and is completing a
comprehensive assessment. The nurse is appropriately applying standard precautions
by performing which of the following actions?
• Performing hand hygiene between examinations of each body part
• Discarding in the trash can the safety pin that was used to assess sensory
perception
• Wearing gloves to palpate the tongue and buccal membranes
• Wearing a gown, gloves, and mask during the physical exam
• The nurse is using a Wood's light for a patient who has complaints of itching,
burning, and peeling of the skin between his toes. The nurse is assessing for what
etiology of the patient's symptoms?
• Parasitic infection
• Fungal infection
• Bacterial infection
• Allergic reaction
• A nurse has gathered the necessary equipment for the physical assessment of an
adult patient. For which of the following assessments would it be most appropriate
for a nurse to use a centimeter-scale ruler for measurement?
• Mid-arm circumference
• patient's height
• Skin lesion size
• Pupillary size
• The nurse is preparing to assess an older adult patient's near vision. Which of
the following pieces of equipment would be most appropriate for the nurse to
use?
• Newspaper
• Snellen chart
• Ophthalmoscope
• Penlight
• Providing a comfortable, warm room temperature
• Arranging exam equipment on a bedside tray table
• Explaining why standard precautions are being used
• A nurse is admitting a new patient to the subacute medical unit and is completing a
comprehensive assessment. The nurse is appropriately applying standard precautions
by performing which of the following actions?
• Performing hand hygiene between examinations of each body part
• Discarding in the trash can the safety pin that was used to assess sensory
perception
• Wearing gloves to palpate the tongue and buccal membranes
• Wearing a gown, gloves, and mask during the physical exam
• The nurse is using a Wood's light for a patient who has complaints of itching,
burning, and peeling of the skin between his toes. The nurse is assessing for what
etiology of the patient's symptoms?
• Parasitic infection
• Fungal infection
• Bacterial infection
• Allergic reaction
• A nurse has gathered the necessary equipment for the physical assessment of an
adult patient. For which of the following assessments would it be most appropriate
for a nurse to use a centimeter-scale ruler for measurement?
• Mid-arm circumference
• patient's height
• Skin lesion size
• Pupillary size
• The nurse is preparing to assess an older adult patient's near vision. Which of
the following pieces of equipment would be most appropriate for the nurse to
use?
• Newspaper
• Snellen chart
• Ophthalmoscope
• Penlight
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• A nurse practitioner is performing a comprehensive physical examination of a 51-
year- old man. After performing a digital-rectal exam for prostate enlargement and
tenderness, the nurse checks the fecal material on the gloved finger for the presence
of which of the following?
• Parasites
• Blood
• Bacteria
• Fungus
• The nurse is examining an older adult patient and using a goniometer. Which of
the following would the nurse be assessing?
• Extremity edema
• Joint flexion/extension
• Two-point discrimination
• Vibratory sensation
• A female patient is told that she needs a pelvic exam and Papanicolaou (Pap) smear.
She says ìAbsolutely not! There's no way I'll let you do that to me!î Which response
by the nurse would be most appropriate?
• Explain the importance of the pelvic exam and Pap smear, but respect the patient's
wishes and omit the exam.
• Tell the patient that this is the only way she can be checked for cancer.
• Ask the patient if she would prefer another practitioner to perform the exam.
• Proceed with the pelvic exam and document the patient's protests in the
health record.
• The nurse is preparing to perform a physical examination on a female patient who
has been transferred to the medical unit from the emergency department. The nurse
should begin the collection of objective data with which of the following
examinations?
• Head and neck examination
• Palpation of lymph nodes
• Breast examination
• Vital signs
• The nurse is to collect a throat culture from a patient who has signs and symptoms of
a respiratory infection, including frequent, productive coughing. The nurse
demonstrates the best adherence to standard precautions by using which of the
following pieces of equipment?
• Eye goggles
year- old man. After performing a digital-rectal exam for prostate enlargement and
tenderness, the nurse checks the fecal material on the gloved finger for the presence
of which of the following?
• Parasites
• Blood
• Bacteria
• Fungus
• The nurse is examining an older adult patient and using a goniometer. Which of
the following would the nurse be assessing?
• Extremity edema
• Joint flexion/extension
• Two-point discrimination
• Vibratory sensation
• A female patient is told that she needs a pelvic exam and Papanicolaou (Pap) smear.
She says ìAbsolutely not! There's no way I'll let you do that to me!î Which response
by the nurse would be most appropriate?
• Explain the importance of the pelvic exam and Pap smear, but respect the patient's
wishes and omit the exam.
• Tell the patient that this is the only way she can be checked for cancer.
• Ask the patient if she would prefer another practitioner to perform the exam.
• Proceed with the pelvic exam and document the patient's protests in the
health record.
• The nurse is preparing to perform a physical examination on a female patient who
has been transferred to the medical unit from the emergency department. The nurse
should begin the collection of objective data with which of the following
examinations?
• Head and neck examination
• Palpation of lymph nodes
• Breast examination
• Vital signs
• The nurse is to collect a throat culture from a patient who has signs and symptoms of
a respiratory infection, including frequent, productive coughing. The nurse
demonstrates the best adherence to standard precautions by using which of the
following pieces of equipment?
• Eye goggles
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• Face mask
• Cover gown
• Face shield
• The nurse is preparing to perform the physical examination of an older adult patient
who will begin rehabilitation from an ischemic stroke. Which of the following actions
would be most appropriate?
• Omit intrusive parts of the exam.
• Try to minimize position changes.
• Allow patient to remain dressed.
• Dim the room light to ensure privacy.
• The nurse is preparing to assess the peripheral pulses of a patient. The nurse should
place the patient in which position?
• Sitting upright
• Supine
• Sims position
• Prone
• When assessing the temperature of the feet of an older patient with diabetes, the
nurse would use which part of the hand to obtain the most accurate assessment
data?
• Finger pad surface
• Palmar hand surface
• Dorsal hand surface
• Ulnar hand surface
• A patient has a documented history of hepatomegaly (liver enlargement), and the
nurse recognizes the need to perform deep palpation during the physical
assessment. The nurse should perform which of the following actions?
• Use one hand and depress the skin 1 centimeter.
• Use the dominant hand to depress the skin one-half to three-quarters of an inch.
• Use both hands to depress the skin one-half of an inch.
• Use both hands to depress the skin 1 to 2 inches.
• The emergency department (ED) nurse is assessing for kidney tenderness in a
patient who has presented with complaints of dysuria and back pain. What
assessment technique should the nurse utilize?
• Deep palpation
• Cover gown
• Face shield
• The nurse is preparing to perform the physical examination of an older adult patient
who will begin rehabilitation from an ischemic stroke. Which of the following actions
would be most appropriate?
• Omit intrusive parts of the exam.
• Try to minimize position changes.
• Allow patient to remain dressed.
• Dim the room light to ensure privacy.
• The nurse is preparing to assess the peripheral pulses of a patient. The nurse should
place the patient in which position?
• Sitting upright
• Supine
• Sims position
• Prone
• When assessing the temperature of the feet of an older patient with diabetes, the
nurse would use which part of the hand to obtain the most accurate assessment
data?
• Finger pad surface
• Palmar hand surface
• Dorsal hand surface
• Ulnar hand surface
• A patient has a documented history of hepatomegaly (liver enlargement), and the
nurse recognizes the need to perform deep palpation during the physical
assessment. The nurse should perform which of the following actions?
• Use one hand and depress the skin 1 centimeter.
• Use the dominant hand to depress the skin one-half to three-quarters of an inch.
• Use both hands to depress the skin one-half of an inch.
• Use both hands to depress the skin 1 to 2 inches.
• The emergency department (ED) nurse is assessing for kidney tenderness in a
patient who has presented with complaints of dysuria and back pain. What
assessment technique should the nurse utilize?
• Deep palpation
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• Indirect percussion
• Moderate palpation
• Blunt percussion
• In the course of performing a patient's physical assessment, the nurse has changed
from using the diaphragm of the stethoscope to using the bell. The nurse is most
likely assessing which of the following?
• Heart sounds
• Bowel sounds
• Breath sounds
• Femoral pulses
• An instructor is teaching a student about the proper use of a stethoscope. The
instructor determines the need for additional teaching when the student states which
of the following?
• ìPlastic tubing should be longer than 3 feet.î
• ìThe bell is used after using the diaphragm.î
• ìWhen using the bell, push on it lightly.î
• ìA diaphragm picks up low-pitched sounds.î
• A nurse is preparing to perform the physical examination of an adult patient who has
presented to the clinic for the first time. Which of the following statements should
guide the nurse's use of a stethoscope during this phase of assessment?
• Auscultation can be performed through clothing.
• The diaphragm should be held firmly against the body part.
• The bell of the stethoscope can best detect bowel sounds.
• Use of the bell is reserved for advanced practice nurses.
• A nurse is appraising a colleague's assessment technique as part of a continuing
education initiative. The nurse demonstrates the proper technique for light palpation
by performing which of the following actions?
• Depressing the skin 1 to 2 centimeters with the dominant hand
• Feeling the surface structures using a circular motion
• Placing the nondominant hand on top of the dominant hand
• Using one hand to apply pressure and the other hand to feel the structure
• The nurse is preparing to examine an older adult patient. Which of the following
would be most appropriate for the nurse to do during the examination?
• Complete the examination as quickly as possible.
• Speak clearly and slowly when explaining a procedure.
• Moderate palpation
• Blunt percussion
• In the course of performing a patient's physical assessment, the nurse has changed
from using the diaphragm of the stethoscope to using the bell. The nurse is most
likely assessing which of the following?
• Heart sounds
• Bowel sounds
• Breath sounds
• Femoral pulses
• An instructor is teaching a student about the proper use of a stethoscope. The
instructor determines the need for additional teaching when the student states which
of the following?
• ìPlastic tubing should be longer than 3 feet.î
• ìThe bell is used after using the diaphragm.î
• ìWhen using the bell, push on it lightly.î
• ìA diaphragm picks up low-pitched sounds.î
• A nurse is preparing to perform the physical examination of an adult patient who has
presented to the clinic for the first time. Which of the following statements should
guide the nurse's use of a stethoscope during this phase of assessment?
• Auscultation can be performed through clothing.
• The diaphragm should be held firmly against the body part.
• The bell of the stethoscope can best detect bowel sounds.
• Use of the bell is reserved for advanced practice nurses.
• A nurse is appraising a colleague's assessment technique as part of a continuing
education initiative. The nurse demonstrates the proper technique for light palpation
by performing which of the following actions?
• Depressing the skin 1 to 2 centimeters with the dominant hand
• Feeling the surface structures using a circular motion
• Placing the nondominant hand on top of the dominant hand
• Using one hand to apply pressure and the other hand to feel the structure
• The nurse is preparing to examine an older adult patient. Which of the following
would be most appropriate for the nurse to do during the examination?
• Complete the examination as quickly as possible.
• Speak clearly and slowly when explaining a procedure.
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• Begin the examination with auscultation instead of inspection.
• Maintain the supine position for each part of the examination.
• The nurse assists a patient into the dorsal recumbent position. Assessment of which
area is contraindicated when the patient is in this position?
• Chest
• Head
• Peripheral pulses
• Abdomen
• The nurse is gathering the necessary equipment preparatory to examining a patient's
ears. The nurse will be checking bone and air conduction of sound. Which of the
following should the nurse obtain?
• Penlight
• Tongue depressor
• Tuning fork
• Otoscope
• The nurse is evaluating the setting prior to beginning a patient's physical
examination. The nurse should confirm the presence of which of the following?
Select all that apply.
• Adequate lighting
• Cool room temperature
• Quiet surroundings
• Soft chair or table
• Table for equipment
• Door or curtain
• The nurse is using her fingerpads to palpate a patient's body part during the
physical examination. Which of the following would the nurse best be able to
detect?
• Temperature
• Vibrations
• Pulses
• Fremitus
• A nurse is reviewing the four basic physical examination techniques and their
sequence prior to receiving a new patient from postanesthetic recovery. The nurse
should plan to perform which technique first?
• Inspection
• Maintain the supine position for each part of the examination.
• The nurse assists a patient into the dorsal recumbent position. Assessment of which
area is contraindicated when the patient is in this position?
• Chest
• Head
• Peripheral pulses
• Abdomen
• The nurse is gathering the necessary equipment preparatory to examining a patient's
ears. The nurse will be checking bone and air conduction of sound. Which of the
following should the nurse obtain?
• Penlight
• Tongue depressor
• Tuning fork
• Otoscope
• The nurse is evaluating the setting prior to beginning a patient's physical
examination. The nurse should confirm the presence of which of the following?
Select all that apply.
• Adequate lighting
• Cool room temperature
• Quiet surroundings
• Soft chair or table
• Table for equipment
• Door or curtain
• The nurse is using her fingerpads to palpate a patient's body part during the
physical examination. Which of the following would the nurse best be able to
detect?
• Temperature
• Vibrations
• Pulses
• Fremitus
• A nurse is reviewing the four basic physical examination techniques and their
sequence prior to receiving a new patient from postanesthetic recovery. The nurse
should plan to perform which technique first?
• Inspection
Loading page 21...
• Palpation
• Percussion
• Auscultation
• The nurse is percussing the area over the patient's lungs and hears a loud, low-
pitched, hollow sound. The nurse documents this finding as which of the
following?
• Flatness
• Resonance
• Tympany
• Dullness
• A 20-year-old female patient has presented to the clinic, and the nurse is preparing to
perform a comprehensive assessment. The patient states, ìI'd really like to have my
mom in the room. That's okay, isn't it?î How should the nurse best respond to the
patient's request?
• ìOf course. There's a chair in the exam room where she can sit.î
• ìThat's no problem. I'll just have to get you to sign a privacy waiver first.î
• ìThat's fine, but be aware that some of the examinations might be embarrassing
for you or her.î
• ìIt's best to undergo the examination alone in order to make sure I get
accurate data, but if you really want her present, we can do that.î
• The nurse is inspecting the dominant hand of an older adult patient and notes the
presence of irregularly shaped brown lesions on the dorsal surface of the patient's
hand. What action should the nurse perform next?
• Obtain a tissue sample for pathology
• Compare the appearance of the patient's other hand
• Palpate the lesions for tenderness and warmth
• Perform health promotion teaching about sun protection
• A young man has presented to the clinic with a 2-week history of head
congestion, fever, and malaise. What assessment technique should the nurse
utilize to assess for sinus tenderness?
• Light palpation
• Deep palpation
• Direct percussion
• Blunt percussion
• Percussion
• Auscultation
• The nurse is percussing the area over the patient's lungs and hears a loud, low-
pitched, hollow sound. The nurse documents this finding as which of the
following?
• Flatness
• Resonance
• Tympany
• Dullness
• A 20-year-old female patient has presented to the clinic, and the nurse is preparing to
perform a comprehensive assessment. The patient states, ìI'd really like to have my
mom in the room. That's okay, isn't it?î How should the nurse best respond to the
patient's request?
• ìOf course. There's a chair in the exam room where she can sit.î
• ìThat's no problem. I'll just have to get you to sign a privacy waiver first.î
• ìThat's fine, but be aware that some of the examinations might be embarrassing
for you or her.î
• ìIt's best to undergo the examination alone in order to make sure I get
accurate data, but if you really want her present, we can do that.î
• The nurse is inspecting the dominant hand of an older adult patient and notes the
presence of irregularly shaped brown lesions on the dorsal surface of the patient's
hand. What action should the nurse perform next?
• Obtain a tissue sample for pathology
• Compare the appearance of the patient's other hand
• Palpate the lesions for tenderness and warmth
• Perform health promotion teaching about sun protection
• A young man has presented to the clinic with a 2-week history of head
congestion, fever, and malaise. What assessment technique should the nurse
utilize to assess for sinus tenderness?
• Light palpation
• Deep palpation
• Direct percussion
• Blunt percussion
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Answer Key
• D
• A
• C
• B
• C
• A
• B
• B
• A
• D
• D
• B
• B
• C
• D
• D
• A
• C
• B
• B
• B
• D
• C
• A, C, E, F
• C
• A
• B
• A
• B
• C
• A nurse is completing the intake assessment of an older adult who has just relocated to
a long-term care facility. Which of the following nursing actions would be most
important to ensure accurate data when gathering the resident's information?
• Documenting the data
• Validating the data
• Identifying patient support systems
• Determining patient needs
• D
• A
• C
• B
• C
• A
• B
• B
• A
• D
• D
• B
• B
• C
• D
• D
• A
• C
• B
• B
• B
• D
• C
• A, C, E, F
• C
• A
• B
• A
• B
• C
• A nurse is completing the intake assessment of an older adult who has just relocated to
a long-term care facility. Which of the following nursing actions would be most
important to ensure accurate data when gathering the resident's information?
• Documenting the data
• Validating the data
• Identifying patient support systems
• Determining patient needs
Loading page 23...
• A nurse is assessing a female patient whose worsening sciatica has prompted her to
seek care. Which of the patient's following statements would the nurse most likely
need to validate?
• ìI don't generally have problems with pain.î
• ìI feel very weak and tired right now.î
• ìI've had two cesarean deliveries.î
• ìMy mother died of breast cancer in her sixties.î
• A patient who had a mastectomy is being discharged home on postoperative day 1.
Knowing that the patient lives alone, which data would be most important for the
nurse to validate for this patient?
• If the patient has transportation for follow-up appointments
• If the patient usually functions independently
• What support systems are in place to assist the patient
• If the patient has a religious belief regarding illness
• When describing the importance of documenting initial assessment data to a group
of new nurses, which of the following would the nurse emphasize as the primary
reason?
• Health care institutions have established policies regarding documentation.
• Incorrect conclusions may be made without documentation of the nurse's opinions.
• It satisfies legal standards established by health care organizations and institutions.
• It becomes the foundation for the entire nursing process.
• A nurse has documented the nursing history and physical examination of a patient.
This health information is best described as which of the following?
• Subjective data and objective data
• Interpretation and inference
• Observation and inspection
• Data and results
• The nurse is caring for a patient with influenza symptoms and is documenting the
initial and ongoing assessment database. Which of the following would the nurse
emphasize as the major rationale for this action?
• Reducing the fragmentation of care
• Maximizing the efficiency of care
• Promoting communication between disciplines
• Facilitating achievement of professional standards
seek care. Which of the patient's following statements would the nurse most likely
need to validate?
• ìI don't generally have problems with pain.î
• ìI feel very weak and tired right now.î
• ìI've had two cesarean deliveries.î
• ìMy mother died of breast cancer in her sixties.î
• A patient who had a mastectomy is being discharged home on postoperative day 1.
Knowing that the patient lives alone, which data would be most important for the
nurse to validate for this patient?
• If the patient has transportation for follow-up appointments
• If the patient usually functions independently
• What support systems are in place to assist the patient
• If the patient has a religious belief regarding illness
• When describing the importance of documenting initial assessment data to a group
of new nurses, which of the following would the nurse emphasize as the primary
reason?
• Health care institutions have established policies regarding documentation.
• Incorrect conclusions may be made without documentation of the nurse's opinions.
• It satisfies legal standards established by health care organizations and institutions.
• It becomes the foundation for the entire nursing process.
• A nurse has documented the nursing history and physical examination of a patient.
This health information is best described as which of the following?
• Subjective data and objective data
• Interpretation and inference
• Observation and inspection
• Data and results
• The nurse is caring for a patient with influenza symptoms and is documenting the
initial and ongoing assessment database. Which of the following would the nurse
emphasize as the major rationale for this action?
• Reducing the fragmentation of care
• Maximizing the efficiency of care
• Promoting communication between disciplines
• Facilitating achievement of professional standards
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• A nurse has completed a patient's initial assessment and is now interpreting and
making inferences from the data. The nurse is involved in which phase of the
nursing process?
• Analysis
• Planning
• Implementation
• Evaluation
• A 54-year-old patient is receiving a follow-up assessment in a clinic, following
abnormal findings on her recent mammogram. Which of the following statements
best reflects appropriate documentation by the nurse?
• ìpatient depressed because of fear of breast biopsyî
• ìpatient with lower back painî
• ìpatient has unkempt appearance and avoids eye contactî
• ìpatient has good lung sounds in right and left lungsî
• A nurse is working in a health care facility that uses charting by exception. Which of
the following would the nurse expect to document?
• Liver palpation normal
• No tenderness on palpation
• Bowel sounds normoactive
• Decreased range of motion in right shoulder
• A task force has been established at a hospital with the aim of overhauling the
assessment forms that are used throughout the facility. Which of the following options
is most likely to help standardize the process of data collection?
• Open-ended form
• Integrated cued checklist form
• Cued or checklist form
• Nursing minimum data set
• A nurse is providing in-service training to a group of nurses in a facility that has
just begun to use an integrated cued checklist for documentation. Which of the
following would the nurse identify as a major advantage of this type of
documentation?
• It helps nurses to cluster assessment data.
• It provides lines for the nurses' comments.
• It includes specialized data particular to each patient.
• It standardizes data collection.
making inferences from the data. The nurse is involved in which phase of the
nursing process?
• Analysis
• Planning
• Implementation
• Evaluation
• A 54-year-old patient is receiving a follow-up assessment in a clinic, following
abnormal findings on her recent mammogram. Which of the following statements
best reflects appropriate documentation by the nurse?
• ìpatient depressed because of fear of breast biopsyî
• ìpatient with lower back painî
• ìpatient has unkempt appearance and avoids eye contactî
• ìpatient has good lung sounds in right and left lungsî
• A nurse is working in a health care facility that uses charting by exception. Which of
the following would the nurse expect to document?
• Liver palpation normal
• No tenderness on palpation
• Bowel sounds normoactive
• Decreased range of motion in right shoulder
• A task force has been established at a hospital with the aim of overhauling the
assessment forms that are used throughout the facility. Which of the following options
is most likely to help standardize the process of data collection?
• Open-ended form
• Integrated cued checklist form
• Cued or checklist form
• Nursing minimum data set
• A nurse is providing in-service training to a group of nurses in a facility that has
just begun to use an integrated cued checklist for documentation. Which of the
following would the nurse identify as a major advantage of this type of
documentation?
• It helps nurses to cluster assessment data.
• It provides lines for the nurses' comments.
• It includes specialized data particular to each patient.
• It standardizes data collection.
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• A group of nursing students is reviewing the purposes of assessment documentation
in preparation for a class discussion. The students demonstrate understanding of the
information when they identify which of the following as one of the primary
purposes?
• It provides a chronologic source of patient assessment data.
• It creates a database for care that was not rendered to the patient.
• It replaces the patient acuity classification system.
• It directly formulates the nursing diagnoses.
• A nurse is comparing the subjective data and objective data obtained from an
assessment of a patient who is thought to have hepatitis A. This nurse's comparison
will achieve what benefit to this patient's care?
• Formulation of nursing diagnoses
• Identification of missing data
• Determination of documentation form to use
• Validation of data
• A nurse is preparing an in-service education program for a group of staff nurses
about documentation, including documentation of assessment data. The nurse
demonstrates understanding of the significance of documentation by including a
discussion of which of the following as playing a role in this area? Select all that
apply.
• Joint Commission
• State nurse practice act
• Medicare
• Local or city government
• Institutional agency
• A nurse has completed an assessment of a patient with cholecystitis and is
about to document the findings. Which statement best reflects accurate
documentation?
• patient appears upset about upcoming surgery.
• patient was interviewed about previous history of hypertension.
• Skin pale, warm, and dry without evidence of lesions.
• patient's oral intake is satisfactory.
• A nurse is using a nursing minimum data set to document findings following
the assessment of a patient. This nurse is most likely providing care in which
setting?
• Acute care facility
• Long-term care facility
in preparation for a class discussion. The students demonstrate understanding of the
information when they identify which of the following as one of the primary
purposes?
• It provides a chronologic source of patient assessment data.
• It creates a database for care that was not rendered to the patient.
• It replaces the patient acuity classification system.
• It directly formulates the nursing diagnoses.
• A nurse is comparing the subjective data and objective data obtained from an
assessment of a patient who is thought to have hepatitis A. This nurse's comparison
will achieve what benefit to this patient's care?
• Formulation of nursing diagnoses
• Identification of missing data
• Determination of documentation form to use
• Validation of data
• A nurse is preparing an in-service education program for a group of staff nurses
about documentation, including documentation of assessment data. The nurse
demonstrates understanding of the significance of documentation by including a
discussion of which of the following as playing a role in this area? Select all that
apply.
• Joint Commission
• State nurse practice act
• Medicare
• Local or city government
• Institutional agency
• A nurse has completed an assessment of a patient with cholecystitis and is
about to document the findings. Which statement best reflects accurate
documentation?
• patient appears upset about upcoming surgery.
• patient was interviewed about previous history of hypertension.
• Skin pale, warm, and dry without evidence of lesions.
• patient's oral intake is satisfactory.
• A nurse is using a nursing minimum data set to document findings following
the assessment of a patient. This nurse is most likely providing care in which
setting?
• Acute care facility
• Long-term care facility
Loading page 26...
• Urgent care center
• Health clinic
• While performing the initial assessment of a patient, the patient tells the nurse that
this is his first hospitalization and that he has no previous surgeries. The nurse
should document which of the following?
• patient denies prior hospitalizations and surgeries
• patient has not been hospitalized before nor has he had any surgery
• patient answered no to previous hospitalizations or surgery
• Negative for past hospitalizations
• An instructor is describing various ways that a nurse can validate data to a group of
nursing students. The instructor determines that additional teaching is necessary
when the students identify which of the following as a reliable method?
• Repeating the assessment
• Asking additional questions
• Having the patient repeat what was said
• Checking findings with another health care professional
• A nurse is working on an acute neurological unit. Which assessment form would
the nurse most likely use to document assessment data?
• Open-ended form
• Focused assessment form
• Frequent assessment form
• Ongoing assessment form
• A group of students is reviewing information from class about the purposes of
assessment documentation. The students demonstrate understanding of the
material when they state which of the following?
• ìDocumentation helps support reimbursement but gives little epidemiologic data.î
• ìDocumentation provides a permanent legal record of care given and not given.î
• ìDocumentation is a viable means of communication but is repetitious.î
• ìDocumentation helps determine patient education needs but not staff mix.î
• A nurse is providing a verbal update to a patient's primary care provider because of
the patient's worsening nausea. When using an SBAR format to provide a report,
the nurse should complete the report with which of the following statements?
• ìWhat would you like to do to address this patient's nausea?î
• ìI think this patient would benefit from an antiemetic.î
• Health clinic
• While performing the initial assessment of a patient, the patient tells the nurse that
this is his first hospitalization and that he has no previous surgeries. The nurse
should document which of the following?
• patient denies prior hospitalizations and surgeries
• patient has not been hospitalized before nor has he had any surgery
• patient answered no to previous hospitalizations or surgery
• Negative for past hospitalizations
• An instructor is describing various ways that a nurse can validate data to a group of
nursing students. The instructor determines that additional teaching is necessary
when the students identify which of the following as a reliable method?
• Repeating the assessment
• Asking additional questions
• Having the patient repeat what was said
• Checking findings with another health care professional
• A nurse is working on an acute neurological unit. Which assessment form would
the nurse most likely use to document assessment data?
• Open-ended form
• Focused assessment form
• Frequent assessment form
• Ongoing assessment form
• A group of students is reviewing information from class about the purposes of
assessment documentation. The students demonstrate understanding of the
material when they state which of the following?
• ìDocumentation helps support reimbursement but gives little epidemiologic data.î
• ìDocumentation provides a permanent legal record of care given and not given.î
• ìDocumentation is a viable means of communication but is repetitious.î
• ìDocumentation helps determine patient education needs but not staff mix.î
• A nurse is providing a verbal update to a patient's primary care provider because of
the patient's worsening nausea. When using an SBAR format to provide a report,
the nurse should complete the report with which of the following statements?
• ìWhat would you like to do to address this patient's nausea?î
• ìI think this patient would benefit from an antiemetic.î
Loading page 27...
• ìThis patient has no recent history of any nausea or vomiting.î
• ìThis patient rates his nausea as seven out of ten.î
• A surgical patient's pain has become increasingly severe overnight, and she has
received her maximum current doses of analgesics. The nurse has consequently
phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the
nurse the new order, how should the nurse best validate this information?
• Read the order back to the surgeon for confirmation.
• Compare the order with the standard timing and dosage of the analgesic.
• Compare the order to the patient's existing medication administration record
(MAR).
• Have another nurse read the order that the nurse has transcribed.
• An audit of a hospital unit's incident reports reveals that several errors have resulted
from incomplete or inaccurate information during change-of-shift handoff. In order
to prevent such errors, what practice should be encouraged on the unit?
• Delegate handoff reports to unlicensed care providers who have fewer demands
on their time.
• Use an intermediary to receive report from the first nurse and then provide
the handoff report to the second nurse.
• Involve as few people as possible in the verbal report.
• Encourage nurses to perform handoff as quickly as possible.
• A patient has illuminated his call light and tells the nurse that he is having ìten out of
tenî pain. The nurse's initial inspection reveals that the patient is watching videos on
his tablet computer and appears to be at ease physically and emotionally. How should
the nurse validate the patient's subjective complaint of pain?
• Ask the patient to repeat his rating of his pain.
• Observe the patient for several seconds to see if his demeanor or his
behavior changes.
• Consult the patient's medication administration record (MAR) to check for
recent analgesic use.
• Perform further assessments addressing various aspects of the patient's pain.
• A hospital nurse is admitting a patient with a documented history of acute
pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What
assessment finding would most clearly warrant validation?
• The patient's blood pressure is 148/88 mm Hg.
• The patient is oriented to person and place but not to time.
• The patient states that she only drinks alcohol on a social basis.
• The patient states, ìMy skin's kind of yellow because of my liver.î
• ìThis patient rates his nausea as seven out of ten.î
• A surgical patient's pain has become increasingly severe overnight, and she has
received her maximum current doses of analgesics. The nurse has consequently
phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the
nurse the new order, how should the nurse best validate this information?
• Read the order back to the surgeon for confirmation.
• Compare the order with the standard timing and dosage of the analgesic.
• Compare the order to the patient's existing medication administration record
(MAR).
• Have another nurse read the order that the nurse has transcribed.
• An audit of a hospital unit's incident reports reveals that several errors have resulted
from incomplete or inaccurate information during change-of-shift handoff. In order
to prevent such errors, what practice should be encouraged on the unit?
• Delegate handoff reports to unlicensed care providers who have fewer demands
on their time.
• Use an intermediary to receive report from the first nurse and then provide
the handoff report to the second nurse.
• Involve as few people as possible in the verbal report.
• Encourage nurses to perform handoff as quickly as possible.
• A patient has illuminated his call light and tells the nurse that he is having ìten out of
tenî pain. The nurse's initial inspection reveals that the patient is watching videos on
his tablet computer and appears to be at ease physically and emotionally. How should
the nurse validate the patient's subjective complaint of pain?
• Ask the patient to repeat his rating of his pain.
• Observe the patient for several seconds to see if his demeanor or his
behavior changes.
• Consult the patient's medication administration record (MAR) to check for
recent analgesic use.
• Perform further assessments addressing various aspects of the patient's pain.
• A hospital nurse is admitting a patient with a documented history of acute
pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What
assessment finding would most clearly warrant validation?
• The patient's blood pressure is 148/88 mm Hg.
• The patient is oriented to person and place but not to time.
• The patient states that she only drinks alcohol on a social basis.
• The patient states, ìMy skin's kind of yellow because of my liver.î
Loading page 28...
• A small, rural hospital is revising the policies and procedures surrounding
documentation in an effort to align practices with the Health Information
Technology for Economic and Clinical Health (HITECH) Act. How can the
requirements of this legislation best be met?
• Expand the use of the Nursing Minimum Data Set.
• Eliminate the use of verbal handoffs between nurses.
• Increase interdisciplinary collaboration in the hospital.
• Increase the use of electronic health records (EHRs) in the hospital.
• The nurse is reviewing and analyzing data from the initial assessment of a
newly admitted patient who is a 79-year-old man. What assessment finding
most clearly indicates a need for further data?
• The man has male pattern baldness.
• The man has a diffuse rash on his torso.
• The man's heart rate is 63 beats per minute.
• The man had an inguinal hernia repair in 2008.
• There has been some resistance to the planned transition to electronic health
records (EHRs) in a hospital system, with many caregivers questioning the
rationale for this change in practice. What potential advantage of EHRs should
administrators cite?
• Increased influence for the nursing profession
• Elimination of documentation
• Improved continuity of care
• Reduced nursing workload
• While assisting an older adult with morning hygiene, the nurse notes a lesion on the
patient's coccyx region. How should the nurse best document this objective
assessment finding?
• ìPossible pressure ulcer observed over patient's coccyx region.î
• ìReddened area noted on skin surface superficial to patient's coccyx.î
• ìArea of nonblanching erythema noted over patient's coccyx, 2 cm ◊ 2 cm.î
• ìImpaired Skin Integrity related to decreased mobility.î
• A nurse is conscientious in adhering to the requirements of the Health Insurance
Portability and Accountability Act (HIPAA) when providing care for patients.
What action best meets these legal requirements for care?
• Having a colleague audit the nurse's documentation to ensure objectivity
• Maintaining the privacy and confidentiality of patients' medical records
• Using electronic records whenever possible, rather than paper-based records
documentation in an effort to align practices with the Health Information
Technology for Economic and Clinical Health (HITECH) Act. How can the
requirements of this legislation best be met?
• Expand the use of the Nursing Minimum Data Set.
• Eliminate the use of verbal handoffs between nurses.
• Increase interdisciplinary collaboration in the hospital.
• Increase the use of electronic health records (EHRs) in the hospital.
• The nurse is reviewing and analyzing data from the initial assessment of a
newly admitted patient who is a 79-year-old man. What assessment finding
most clearly indicates a need for further data?
• The man has male pattern baldness.
• The man has a diffuse rash on his torso.
• The man's heart rate is 63 beats per minute.
• The man had an inguinal hernia repair in 2008.
• There has been some resistance to the planned transition to electronic health
records (EHRs) in a hospital system, with many caregivers questioning the
rationale for this change in practice. What potential advantage of EHRs should
administrators cite?
• Increased influence for the nursing profession
• Elimination of documentation
• Improved continuity of care
• Reduced nursing workload
• While assisting an older adult with morning hygiene, the nurse notes a lesion on the
patient's coccyx region. How should the nurse best document this objective
assessment finding?
• ìPossible pressure ulcer observed over patient's coccyx region.î
• ìReddened area noted on skin surface superficial to patient's coccyx.î
• ìArea of nonblanching erythema noted over patient's coccyx, 2 cm ◊ 2 cm.î
• ìImpaired Skin Integrity related to decreased mobility.î
• A nurse is conscientious in adhering to the requirements of the Health Insurance
Portability and Accountability Act (HIPAA) when providing care for patients.
What action best meets these legal requirements for care?
• Having a colleague audit the nurse's documentation to ensure objectivity
• Maintaining the privacy and confidentiality of patients' medical records
• Using electronic records whenever possible, rather than paper-based records
Loading page 29...
• Collaborating with the patient and his or her family prior to documenting
Answer Key
• B
• A
• C
• D
• A
• C
• A
• C
• D
• C
• A
• A
• D
• A, B, C, E
• C
• B
• A
• C
• B
• B
• B
• A
• C
• D
• C
• D
• B
• C
• C
• B
• A nurse has completed a comprehensive assessment of a patient and has begun the
process of data analysis. Data analysis should allow the nurse to produce which of
the following direct results?
• Outcomes evaluation
• Nursing diagnoses
• Holistic interventions
Answer Key
• B
• A
• C
• D
• A
• C
• A
• C
• D
• C
• A
• A
• D
• A, B, C, E
• C
• B
• A
• C
• B
• B
• B
• A
• C
• D
• C
• D
• B
• C
• C
• B
• A nurse has completed a comprehensive assessment of a patient and has begun the
process of data analysis. Data analysis should allow the nurse to produce which of
the following direct results?
• Outcomes evaluation
• Nursing diagnoses
• Holistic interventions
Loading page 30...
• An interdisciplinary plan of care
• A new nursing graduate recently made an oversight during the analysis of a
patient's assessment data that resulted in a postoperative complication. What
characteristic of data analysis makes it a challenging aspect of nursing practice?
• Abnormal data must be identified.
• It requires the prior identification of nursing diagnoses.
• It requires sophisticated diagnostic reasoning skills.
• Conclusions must be clearly and accurately documented.
• A hospital nurse has identified a need to improve her critical thinking skills in an
effort to improve patient care. The nurse should identify which of the following
characteristics of critical thinking?
• It is an innate skill that some individuals possess and which others do not.
• It does not include past experiences.
• It is based primarily on getting correct and timely information.
• It involves reflections on thoughts before reaching conclusions.
• The emergency department has collected extensive data from a patient who has
presented with a new onset of severe abdominal pain. What nursing action should the
nurse perform before proceeding with data analysis?
• Validate the collected data.
• Formulate a nursing diagnosis.
• Make inferences about the data.
• Identify the patient's strengths.
• A nurse has completed a patient's initial assessment and is preparing to identify
abnormal data and the patient's strengths. Successful completion of this phase of the
nursing process most requires which of the following?
• Knowledge of anatomy and physiology
• Awareness of the patient's medical prognosis
• Inferences about the patient
• Knowledge about the referral process
• A nurse is planning a patient's care following the completion of an initial
assessment. When formulating a risk nursing diagnosis, which piece of data would
be most useful?
• The patient has an elevated white blood cell count.
• The patient is 66 years of age.
• The patient has pain in her joints, especially in the morning.
• A new nursing graduate recently made an oversight during the analysis of a
patient's assessment data that resulted in a postoperative complication. What
characteristic of data analysis makes it a challenging aspect of nursing practice?
• Abnormal data must be identified.
• It requires the prior identification of nursing diagnoses.
• It requires sophisticated diagnostic reasoning skills.
• Conclusions must be clearly and accurately documented.
• A hospital nurse has identified a need to improve her critical thinking skills in an
effort to improve patient care. The nurse should identify which of the following
characteristics of critical thinking?
• It is an innate skill that some individuals possess and which others do not.
• It does not include past experiences.
• It is based primarily on getting correct and timely information.
• It involves reflections on thoughts before reaching conclusions.
• The emergency department has collected extensive data from a patient who has
presented with a new onset of severe abdominal pain. What nursing action should the
nurse perform before proceeding with data analysis?
• Validate the collected data.
• Formulate a nursing diagnosis.
• Make inferences about the data.
• Identify the patient's strengths.
• A nurse has completed a patient's initial assessment and is preparing to identify
abnormal data and the patient's strengths. Successful completion of this phase of the
nursing process most requires which of the following?
• Knowledge of anatomy and physiology
• Awareness of the patient's medical prognosis
• Inferences about the patient
• Knowledge about the referral process
• A nurse is planning a patient's care following the completion of an initial
assessment. When formulating a risk nursing diagnosis, which piece of data would
be most useful?
• The patient has an elevated white blood cell count.
• The patient is 66 years of age.
• The patient has pain in her joints, especially in the morning.
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Subject
Nursing