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1. What statement defines dementia?
2. During an interview the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. this is example of
3. which of the following is an example of a first level priority problem?
4. A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness is
5. A 45yr old woman is brought to the ER with a head injury after hitting a tree. A few months after her injuries, she's unable to learn new information or recall previously learn information. This is?
6. The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has to come to the clinic today. The woman states that she is and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands and sighs loudly. What statement is most accurate?
7. After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be?
8. Which of the following is the best definition of spirituality?
9. Which of the following examples would be a hallucination?
1) A man believes that his dead wife is talking to him
2) A woman hears the doorbell rings and goes to answer it, but no one is there
3) A child sees a man standing in his closet, when the light s are on it is only a dry cleaning bag.
4) A man believes that the dog has been curled up on the bed, but when her gets closer he sees that it is a blanket: a man believes that his dead wife is talking to him
10. A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information?
11. What data would not be included in a client's health history?
1) laboratory tests
2) physical assessment
4) family medical history
12. Which data would a nurse document under the category of family health history?
2) present illness
3)allergies to meds
4) client's name and birth date:
13. Symptoms such as pain, are often influence by cultural heritage. which statement is true?
14. A client with cancer says "I feel like I am getting weaker everyday I wonder is the chemotherapy is working." the nurse responds "Isn't it a beautiful day?" this interaction is an example of what type of communication barrier.
15. which scenario described below best illustrates a screening type of health assessment?
-a hospital sponsors a health fair at a local mall and provides cholesterol and bp checks to mall patron
-a client visits an obstetric clinic for the first time, and the nurse conducts a detailed history and physical exam
-a client make an appointment 1 month after today's office visit for a fallow-up testing of fasting blood glucose level.
-the nurse in the triage are of an urgent care center checks the vital signs of a client who is complaining of leg pain:
16. the largest and fasting growing population in the U.S is:
17. The following statement could be found at which phase of the interview? "Mr. S.., I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here"
-closing the interview
-during the body of the interview
-opening/introducing the interview:
18. Culture has four basic characteristics. Which statement correctly reflects one of these characteristics?
-cultures are static and unchanging despite changes around them.
-cultures are never specific, which makes them hard to identify
-culture is most clearly reflected in a person's language and behavior
-culture adapts to specific environmental factor and available natural re- sources:
19. the nurse is assessing a new patient who has recently immigrated to the
U.S. which question is appropriate to add to the health history?
-why did you come to the US
-when did you come to the US and from what country?
-what made you leave your native country
-are you planning to return to your home:
20. which of the following culture-bound syndromes is more common among
21. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
22. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of the fluid and electrolyte imbalance. The nurse will assess his:
23. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which of the following statements is true regarding note-taking?
24. A 90-year-old patient tells the nurse that he can't remember the names of the drugs he is taking or what they are for. An appropriate response would be::
25. The nurse is assessing mental status in children. Which of the following statements is true?
-All aspects of mental status in children are interrelated.
-Children are highly labile and unstable until the age of 2 years.
-Children's mental status is largely a function of their parents' level of functioning until the age of 7 years.
-Children's mental status is impossible to assess until the child develops the ability to concentrate.
26. Which intervention by the nurse first helps to establish a trusting nurse-patient relationship?
-provoke emotional responses from the patient
-not listening to the patient while performing care activities
-performing care interventions quickly and efficiently
-greeting the patient by name whenever entering the patient's room:
27. Many individuals embrace the hot/cold theory of health illness. Which of the following best describes the basic tenets of this theory?
-The causation of illness is based on supernatural forces that influence the humors of the body.
-Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body.
-The four humors of the body consist of blood, yellow bile, spiritual connect- edness, and social aspects of the individual.
-The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
28. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
-A trained interpreter
-A male family member
-A female family member
-A volunteer college student from the foreign language studies department.-
: A trained interpreter
29. Which statement is correct regarding the development of one's culture?
-Culture is genetically determined on the basis of racial background.
-Culture is learned through language acquisition and socialization.
-Culture is a nonspecific phenomenon and is adaptive but unnecessary.
-Culture is biologically determined on the basis of physical characteristics.
30. Which of the following statements is true regarding the assessment of mental status?
-Mental status assessment diagnoses specific psychiatric disorders.
-Mental disorders occur in response to everyday life stressors.
-Mental status functioning is inferred through assessment of an individual's behaviors.
-Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).
31. Which data do nurses document under the category of past health histo- ry?
-Allergies to Medications
-Name and date of birth:
32. A 42-year-old Asian patient is being seen at the clinic for an initial exam- ination. The nurse knows that it is important to include cultural information in his health assessment to:
-identify the cause of his illness
-make accurate disease diagnoses.
-provide cultural health rights for the individual
-provide culturally sensitive and appropriate care.
33. Which of following is included in documenting a history source?
-Reliability of informant
-Cognition and literacy level of the client
-"Appearance, dress and hygiene of the client"
-Documented relationship of support systems of the client:
34. Which of the following responses might the nurse expect during a func- tional assessment of a patient whose leg is in a cast?
• "I broke my right leg in a car accident 2 weeks ago."
• "The pain is getting less, but I still need to take Tylenol."
• "I check the color of my toes every evening just like I was taught."
• "I'm able to transfer myself from the wheelchair to the bed without help.": -
35. Which of the following is an example of a folk healer?
36. In response to a question regarding use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
-This is necessary to determine the patient's reliability.
-Alcohol can interact with all medications and make some diseases worse.
-The nurse needs to be able to teach the patient about the dangers of alcohol use.
-It's not really necessary to have this information unless there is an obvious drinking problem.
37. Which of the following illustrates an appropriate category in a cultural assessment?
38. Which of the following is not a barrier to communication?
-failure to listen
39. A nurse that accuses the client of not following a diabetic diet when a serum blood sugar of 200mg/dl is noted. This accusation upsets and angers the client. This response is secondary to which form of communication barrier?
40. The nursing process is a sequential method of problem solving that includes which five steps?
-assessment, treatment, evaluation, discharge, follow-up
-admission, assessment, diagnosis, treatment, discharge planning
-admission, diagnosis, treatment, evaluation, discharge planning
-assessment, diagnosis, planning, implementation, evaluation:
41. Which of the following is an example of an "open-ended question"?
'How have you been feeling today?'
'Did you try home remedies for your symptoms?'
'Did you drive yourself today?'
'Did you call your doctor?'
42. When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situa- tion?
-The nurse should ask someone who knows the patient well to help interpret this discrepancy.
-The nurse should focus on the patient's verbal message and try to ignore the nonverbal behaviors.
-The nurse should try to integrate the verbal and nonverbal messages and then interpret them as an "average."
-The nurse should focus on the patient's nonverbal behaviors because these are often more reflective of a patient's true feelings.
43. "During an interview with your client, she is very talkative and is sharing much information which is not pertinent to the reason for her admission to the hospital. Which action by you would improve your data collection in this particular situation?"
-Facilitate close-ended questions
-Terminate the interview
-Ask the client to stay on the subject
-Ask another nurse to complete the interview:
44. What objective data would a nurse obtain during a physical examination?
-The client's radial and apical pulse
-The client's concern with their financial expenditures
-The client's complaints of numbness and tingling in their feet
-The client's reason for being hospitalized:
45. The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
-"I know that my name is John. I couldn't tell you where I am. I think it is 2027, though."
-"I know that my name is John, but to tell you the truth, I get kind of confused about the date."
-"I know that my name is John; I guess I'm at the hospital in Spokane. No, I
don't know the date."
-"I know that my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2007."
46. "A client arrives at the emergency department with uncontrollable crying and anxiety. The client's spouse of 17 years has recently asked for a divorce. The client is sitting in a chair, rocking back and forth. Which is the best response for the nurse to make?"
-I can see how upset you are. Let's sit in the office so that we can talk about how you're feeling.
-You must stop crying so that we can discuss your feelings about the divorce.
-"Once you find a job, you'll feel much better and more secure."
-" Once you have a lawyer looking out for your interests, you will feel better.
47. Which type of aphasia is the most common and severe form—spon- taneous speech is absent or it is reduced to a few stereotyped words or sounds?
48. A nurse is taking complete health histories on all the patients attending a wellness workshop. On the history form, one of the written question asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:
49. Which of the following statements best describes the purpose of a health history?
-To provide an opportunity for interaction between patient and nurse
-To provide a form for obtaining the patient's biographic information
-To document the normal and abnormal findings of a physical assessment
-To provide a database of subjective information about the patient's past and current health:
50. When the nurse is evaluating the reliability of a patient's responses, which of the following would be a correct statement?
-The patient has a history of drug abuse and therefore is not reliable.
-The patient provided consistent information and therefore is reliable.
-The patient smiled throughout interview and therefore is assumed reliable.
-The patient would not answer questions concerning stress and therefore is not reliable.
51. Which of the following statements represents subjective data obtained from the patient regarding his skin?
Skin appears dry. No obvious lesions Denies color change
Lesion noted lateral aspect right arm:
52. Because the physical environment in which an interview takes place is an important consideration for the success of an interview, the interviewer should:
-reduce noise by turning off televisions and radios.
-place the distance between the interviewer and the patient about 2 feet or closer.
-provide a dim light that makes a room cozier and will help the patient relax.
-arrange seating across a desk or table to allow the patient some personal space.
53. To assess affect, the nurse would know the definition as:
-temporary expression of feeling or state of mind
-being aware of one's own existence, feelings, and thoughts
-more durable, a prolonged display of feelings
-awareness of an object in relation to the self:
54. The germ theory, which posits that microscopic organisms such as bac- teria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?
55. During an assessment, the nurse uses the CAGE test. The patient an- swers "yes" to two of the questions. What could this be indicating?
-The patient is an alcoholic.
-The patient is annoyed at the questions.
-The patient should be examined thoroughly for possible alcohol withdrawal symptoms.
-The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.:
56. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is:
-just changing positions.
-more comfortable in this position.
-tired and needs a break in the interview.
-uncomfortable talking about his son's treatment.
57. A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
objective reflective subjective introspective:
58. In the health promotion model, the focus of the health professional includes:
-changing the patient's perceptions of disease
-identification of biomedical model interventions
-identifying negative health acts of the consumer
-helping the consumer choose a healthier lifestyle:
59. The public's concept of health has changed since the 1950s. Which of the following statements most accurately describes this change?
-Lifestyle, personal habits, exercise, and nutrition are essential to health.
-Assessment of health is critical to identifying disease-causing pathogens.
-Accurate diagnosis and treatment by a physician are essential for all healthcare.
-An individual is considered healthy when signs and symptoms of disease have been eliminated.
60. Why is the concept of prevention essential in describing health?
-Disease can be prevented by treating the external environment.
-The majority of deaths among Americans under age 65 years are not pre- ventable.
-Prevention places emphasis on the link between health and personal behav- ior.
-The means to prevention is through treatment provided by primary health care practitioners.
61. When does the health assessment begin?
-When the nurse initially meets the client
-When the client tells the nurse their name
-When the nurse asks the client the first health-related question
-When the client consents to have a health assessment:
62. During a clinic visit, a patient states, "The doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I've tried. I just don't know the best way to do it. What should I do?" The nurse's most appropriate response in this case would be:
-"I'd quit. The doctor really knows what he is talking about."
-"Would you like some information about the different ways a person can quit smoking?"
-"Stopping your dependence on cigarettes can be very difficult. I understand how you feel."
-"Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer?":
63. An example of objective information obtained during the physical assess- ment includes the:
-patient's history of allergies
-patient's use of medications at home
-last menstrual period 1 month ago
-2.5 cm scar present on the right lower forearm:
64. In recording the childhood illnesses of a patient who denies having had any, which of the following notes by the nurse would be most accurate?
-Patient denies usual childhood illnesses.
-Patient states he was a "very healthy" child.
-Patient states sister had measles, but he didn't.
-Patient denies measles, mumps, rubella, chickenpox, pertussis, or strep throat.
65. Which statement is accurate regarding one's ethnicity?
-Ethnicity is dynamic and ever-changing.
-Ethnicity is the belief in a higher power.
-Ethnicity pertains to a social group within the social system that claims shared values and traditions.
-It is learned from birth through the processes of language acquisition and socialization.
66. Which of the following should a nurse document in the history compo- nent of a health assessment?
67. The nurse is performing a functional assessment on an 82-year-old pa- tient with a recent stroke. Which of the following questions would be most important to ask?
-"Do you wear glasses?"
-"Are you able to dress yourself?"
-"Do you have any thyroid problems?"
-"How many times a day do you have a bowel movement?"
68. Which statement is an appropriate component of one's spirituality?
-Belief in the worship of God or gods
-Attendance at a specific church
-A personal effort to find purpose and meaning in life
-Closely tied to one's ethnic background:
69. What is the step of the nursing process that includes data collection by health history, physical examination, and interview?
planning diagnosis evaluation
70. Which of the following is an example of a symptom? Chest pain
Serum potassium level 4.2 mEq/L
A temperature of 100 degrees F:
71. The first step in understanding the health care needs of another person is:
-identifying the meaning of health to the other person.
-understanding one's own heritage-based cultural values, beliefs, attitudes, and practices relevant to health and illness.
-understanding how the health care delivery system works.
-being knowledgeable about the person's social background.
72. Which of the following individuals would the nurse consider at highest risk for a suicide attempt?
-A man who jokes about death
-A woman who, during a past episode of major depression, attempted suicide
-An adolescent who has just broken up with her boyfriend and states that she would like to kill herself
-An elderly man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun:
73. A description of who lives with a child, the method of discipline, and support system are all related to which part of the assessment?
-Review of systems
-Reason for seeking care:
74. The interview portion of data collection collects:
75. A woman, Mrs. H., has just entered the emergency department after being battered by her husband. The nurse will need to get some information from her to begin treatment. What is the best choice for an opening with this patient?
-"Nancy, my name is Mrs. C."
-"Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
-"Mrs. H., my name is Mrs. C. You sure look like you're in pain, can I get you anything?"
-"Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened.":
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