1. The nurse is preparing to conduct an admission assessment on a 76-year-old man. What would be important to do before interviewing this patient? D. Reduce or eliminate background noise A. Make sure the door is not blocked B. Speak in a louder than normal voice C. Turn up the patient's hearing aid.
2. The nurse is admitting an 83-year-old woman to the short stay unit same day surgery. What information should the nurse have before beginning the interviewed process? A. The patient's view of her own health. B. Whether the patient uses a cane C. Whether the patient is hard of hearing D. The patients educational level.
3. What does the nurse use to formulate a nursing care plan? C. Assessment data A. Obejective data B. Subjective data D. A preprinted care plan.
4. A student nurse asks the instructor why it is necessary to do comprehensive health assessment on a new patient. What would be the instructor best response?
C. The comprehensive health assessment integrates all body system and help give the nurse an overall impression of the patient and his or her condition. A. "A new patient needs a more complete assessment." B. "It is a better assessment than any assessment." D. "You need to know what is going on with the patient at that point in time.".
5. When conducting a focused health assessment, the nurse asks questions specifically targeting what? D. Issues and symptom specific to the patient. A. The patient's culture B. The patient's gender C. The patient's sexual orientation.
6. When collecting subjective data, the nurse gives the patient time and encouragement to do what? D. Tell his or her story B. Express complaints C. Use common findings A. Tell stories about his or her family.
7. A nursing instructor is explaining to students about primary prevention services that the nurses offer as a part of their professional responsibilities. What would the instructor list as these services? C. Screening A. Palpatation B. Auscultation D. Rehabilitation.
8. The nurse is assessing risk factors on a new clinic patient. These risk factors are assessed according to what? D. The individual lifestyle. A. The individual's age B. The individual's risk C. The individual's gender.
9. When considering the culture of patient, the nurse would be aware that in some cultures. A. A health care provider of the same gender. B. Only a male health care provider is acceptable C. A chaperone always has to be with the patient D. A translator is always necessary.
10. The nurse is palpating the abdomen of the patient newly admitted to the unit. What would be an abnormal finding? B. Guarding A. Softness C. Non palpable organs D. Non tender areas.
11. A nurse is caring for a patient with inflammatory bowel changes and has identified a nursing diagnosis of "Diarrhea related to inflammatory changes in the bowel." What would be an appropriate intervention for this diagnosis? B. Ensure adequate hydration and electrolyte replacements. A. Use heat or cold pack for pain relief C. Provide periods of rest by clustering care D. Gather resources for home care and daily activities.
12. To increase the number of people with specific source of ongoing care, what would a nurse teach a patient? A. Review a healthy diet, regular exercise, weight reduction and recommended screenings. B. Remind the patient's with diabetes to get foot checks annually C. Discuss the safe sec practices and encourage patients who are at risk to get testing D. Teach the patient to have a regular visit for screening and health promotion.
13. While admitting a patient to the unit, the patients states, “I am allergic to sulfa drugs”, how would the nurse verify this information? C. Ask the patient about the response to the allergen. A. Ask family members B. Ask the physicians D. Compare against the patient's legal records.
14. A nurse is assessing the patient and collecting only the most important information. Why type of assessment is the nurse doing? D. Focused A. Functional B. Emergency C. Comprehensive.
15. The nurse is conducting a physical assessment. The data nurse would collect vary depending on what? C. The patient cooperation A. How much time the nurse has B. The patient's acuity D. Onset of current symptoms.
16. A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? A. To establish a database against which subsequent assessments can be measured B. To establish rapport with the patient and family C. To gather information for specialists to whom the patient might be referred D. To quantify the degree of pain a patient may be expecting.
17. A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostics statements in the care plan, what would the nurse use? D. Diagnostic reasoning A. Rationale B. ANA recommendations C. Physical assessment skills.
18. A nurse performs a comprehensive assessment on a patient. What is included in this assessment? C. Complete health history A. Circulatory assessment B. Assessment of the airway D. Disability assessment.
19. A nurse is admitting a new patient, the patient is lying. Where should a nurse be positioned? D. Standing beside the bed, looking down at the patient. A. Seated in a chair at eye level with the patient B. Sitting on the side of the bed looking down at the patient C. Leaning on the nightstand at eye level with the patient.
20. During the interviewing process the nurse obtain what type of data from the patient? A. Primary B. Secondary C. Objective D. Oral.
21. The nurse is admitting a new patient to the unit. While reviewing old record of this patient, the nurse knows that the data being gathered are what kind of data? B. Secondary A. Primary C. Subjective D. Objective.
22. A genogram is developed to visually show what? B. Family health patterns. A. Family tree C. Family relationships D. Nationalities of family members.
23. What tools was the nurse use to auscultate the patient abdomen? D. Stethoscope A. None B. Fetoscope C. Sonoscope.
24. When earing the patients in any health environment, what is the most important technique for preventing infection? C. Hand hygiene A. Sterile technique B. Standard precautions D. Use of gloves.
25. When percussing a patient, where would the nurse expect to find the loudest tone? D. Over the lungs A. Over the liver B. Over the bladder C. Over the spleen.
26. As part of general survey, the nurse should shake hands with the patients when first meeting him or her as long as doing so is culturally appropriate. Why is this action so important? C.The handshake allows the nurse to get physically close to the patient in a nonthreatening way A. The handshake portrays earing B. The handshake shows how professional the nurse is D. The handshake allows the nurse to assess how nervous the patient is.
27. A patient arrives at the emergency department by ambulance after an accident while playing softball. His left leg is swollen and deformed. He describes his pain as a 9 on a 10-point scale. When the nurse assesses the patient blood pressure what would he or she expect to find? C. The blood pressure is elevated. A. The blood pressure is lower than normal B. There would be no need to assess the blood pressure D. The blood pressure is within normal limits.
28. A nursing student is caring for a 77-year-old Hispanic woman. The nurse preceptor asks the students what an important assessment would be to make to provide quality nursing care for this client. What would be the student most appropriate response? A. Transcultural assessment B. Respiratory assessment C. Mobility assessment D. Family assessment.
29. Malika is brought to the clinic by her friend, who tells the APRN, that her friend has a sore on her leg, that “just keeps getting bigger”. On examination, the APRN notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the APRN, tell the lesion is? C. Impetigo A. Vericella B. Scabies D. Rubella.
30. A normal assessment of the neck would include palpitation of the thyroid isthmus. Where would the nurse find the isthmus? C. Just below the cricoid cartilage. A. Just above the thyroid cartilage B. Between the thyroid and the cricoid cartilages D. In front of the sternocleidomastoid .
31. A 20-year-old Hispanic male has arrived at the emergency department after a bicycle accident. The paramedic tells the nurse that the patient was not wearing a helmet when he ran into a curb and was thrown over the handlebars, striking his head on the sidewalk. What would be the most important for the nurse to include in the education for this patient? B. Use of safety equipment. A. Where to find bike safety courses C. Use of hand signals when bike riding D. Measuring for the right size bicycle.
32. The nurse is assessing the peripheral vision of a 55-year-old patient. What test would the nurse use to assess the boundaries of the patient peripheral vision? A. Static confrontation B. Allen C. Kinetic confrontation D. Cover .
33. The nurse is caring for a 58-year-old man who presents at the clinic with reports general malaise and fatigue. Physical assessment reveals that the patient’s lips are dry and cracked. Why might this indicate? C. Inadequate hydration. A. Heat stroke B. Vital infection D. Allergy.
34. When assessing whispered pectoriloquy, the nurse would instruct the patient to do which of the following? A. Softly repeat the words "one-two-three." B. Say "ninety-nine" C. Cough each time the stethoscope is moved D. Say the letter "e".
35. When preparing to examine a patient thoracic cage, the nurse would locate which landmark as most helpful in determine where to start? C. Sternal angle A. Sternum B. Suprasternal notch D. Sternal border.
36. A patient has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this patient respiratory effort? A. There is a loss of involuntary respiratory control. B. The patient will respond negatively to increased stimuli C. There is an increased level of carbon dioxide in the blood D. The patient's oxygen levels in the blood will be increased.
37. Which of the following will be the most important for the nurse to remember when auscultating the thorax? A. Listen at each site for at least one complete respiratory cycle. B. Have the patient breath deeply through the mouth C. Be alert to the patient's comfort and offer rest periods D. Auscultate the base at the level of the sixth rib.
38. When percussing the scapula of the patient, which of the following would the nurse expect to hear? C. Flatness A. Resonance B. Dullness D. Hyperresonance.
39. Which of the following would be best for nurse to use when assessing for fremitus in a patient? C. Palmar base (ulnar surface) A. Dorsal hand surface B. Pads of fingers D. Fist.
40. The area known as Erb’s, point in the third site for auscultation on the precordium. Where is located? D. 3rd left rib space. A. 4th left rib space B. 3rd right rib space C. 4th right rib space.
41. A patient comes to the emergency department reporting a sudden onset of dyspnea .What finding is a manifestative of dyspnea? A. Shortness of breath B. Painful breathing C. Rapid breathing D. Inability to breathe.
42. A 79-year-old man has come to the clinic for a routine checkup. He reports general malaise and chronic fatigue, stating” I just can´t get out and work in the garden anymore. I really miss it “. The patient has a history of cardiomegaly with a hyperthophied left ventricle. Where would the nurse expect to find the PMI? A. Between the 4th and the 5th ICS at the MCI. B. Lateral and Inferior to the 4th and the 5th ICS at the MCI. C. Lateral and superior to the 4th and the 5th ICS at the MCI. D. Lower left sternal border.
43. The Lymphatic system when working together with the immune system main functions is? A. Maintain protein balance B. Drain lymph from the bloodstream C. Fight infection D. Hydrate the thymus E. Maintain fluid balance.
44.The nurse is caring for a patient who is vomiting. When inspecting the vomitus, the nurse note that it appears to contain coffee grounds. This would indicate what to the nurse? A. Digested blood B. Decreased peristalsis C. Active bleeding D. Undigested blood.
45. When assessing a patient´s strength, it is necessary to A. Compare one side with the other B. Assesss the extremities at the same time C. Compare upper and lower extremities D. Assess upper and lower extremities at the same time.
46. A patient has sustained an injury to the cerebellum. Which area would be the primary area for assessment? A. Vital signs B. Neurologic system C. Cardiac function D. Coordination.
47. The nurse assess brisk reflex in a patient. The nurse would document this finding as which of the following? C. 3+ A. 1+ B. 2+ D. 5+.
48. During the Romberg’s test a patient is unable to stand with his feet together and demonstrate a wide – based, staggering unsteady gait. The nurse would identify this as which of the following? D. Cerebellar ataxia A. Spastic hemiparesis B. Parkinsonian gait C. Scissor's gait.
49. When chartering it is the nurse legal mandate to record both normal and abnormal assessment data and the correct time. B. False A. True.
50. A nurse in an emergency department is assessing a patient admitted with suspect appendicitis. What type of palpation over the right lower quadrant of this patient would the nurse use? B. Tertiary A. Primary C. Subjective D. Secondary.
51. A patient has come to the clinic for a routine checkup. She is 77 years old, weights 198 pounds, stands 5”4”, and lives alone. Her B/P is 147/89, pulse is 80, and respirations 18. The nurse is planning her patient teaching. What is an appropriate topic to include in Mrs. Kirk’s teaching? a. Keeping floors clear b. Maintaining social contacts c. Encouraging a diet that supports a normal BMI d. Providing information on classes on diabetes.
52. A patient has just been diagnosed with osteopenia. To help prevent progression to osteoporosis, the nurse would teach this patient about what? a. Vitamin D supplements b. Vitamin E supplements c. Vitamin B12 supplements d. Vitamin A supplements .
53. As part of the interview process in a new patient, the nurse is assessing for factors will place the patient vulnerable. these factors are assessed according to what? a. The individual age b. The individual risks c. The individual gender d. The individual lifestyle.
54. A new patient presents at the clinic and report difficulty hearing. During the interview the patient asks the nurse to repeat questions several times. Examination of the ears reveals large amount of cerumen in the canals bilaterally. What would be an appropriate outcome for this patient? a. meaning will be restored to WNI. b. the patient will learn to safely clean ears with cotton swabs. c. ears will be cleaned at the clinic with hearing improved. d. the patient will clean ears at home.
55. When doing a shift assessment on a new patient, the nurse notes that the popliteal pulses are within normal limits (WNL). How the nurse chart this? a. popliteal pulses 1-2 + b. pulses 2-3+ c. pulses 3-4+ d. popliteal pulses 4+.
56. What type of assessment would a hospital nurse perform on a patient being admitted? a. screening b. focused c. acute d. comprehensive.
57. A clinical instructor is teaching a group about organizing data when documenting and communicating findings. The clinical instructor knows that the method she is teaching promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? a. body systems b. comprehensive c. head to toe d. functional .
58. Why is it important for the nurse to obtain the medication history of the patient during its hospitalization and compare it with the medication that the patient regularly takes at home? a. so the physician can order the correct drugs for the hospitalized patient. b. so the patient medication record correlates with the patient’s medication history. c. so the patient continues taking the correct drugs. d. so the physician can make sure to change the patient drugs.
59. The nurse is caring for a patient who on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true? a. The patient develops signs and symptoms. b. Rationale c. Physical assessments skills d. ANA recommendations.
60. The nurse is admitting a patient to the clinic and perform a focused assessment. What make a focused assessment different from a comprehensive assessment? a. Covers the body head to toe b. Occurs only in the clinic area c. Involves all body system d. Is more in depth on the specific issues .
61. The nursing instructor is explaining to students the difference between the language used when a nurse talks to the patient and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record? a. Document according to the orders of the physician b. Talk to the patient and document exactly the same c. Use medical terminology when documenting in the medical record d. Document exactly as the patient talks.
62. Students are learning about the many users of the medical record. During health assessment it helps the health care provider compare current and past visits, these reviews will help a. The evaluation of financial reimbursement b. The evaluation of patient nutrition c. The evaluation of care continual improvement d. The evaluation of timely documentation of pain.
63. Parents bring a child to the clinic and report a “rash” on the knee. On assessment, the RN notes the area to be a reddish-pink lesion covered with silvery scales. What would the APRN chart? a. Seborrhea b. Contact dermatitis c. Eczema d. Psoriasis.
64. An 81-year-old man presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, non-movable mass approximately 20 mm that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding? a. Nodes feel matted together on palpation b. Nodes are delimited on palpation c. Nodes appear grown together on palpation d. Nodes are demarcated on palpation.
65. A 21-year-old girl is brought to the clinic for a reports physical examination. The patient states that she is going to play goalie on the community soccer team. What is the most important teaching opportunity presented for this patient? a. Use of safety equipment b. Prevention of knee injuries c. Prevention of head injuries d. Use of correct foot gear.
66. An RN is conducting the physical assessment of a 22-year-old Caucasian female. The patient`s mother state that it seems like her daughter always has a strep throat. Based on your knowledge, what will be the indication for this patients? a. Dialysis b. Removal of nasal POLYPS c. Sinus surgery d. Tonsillectomy.
67. Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called? a. Epigastric b. Hypogastric c. Hypochondriac d. Inogastric.
69. A nurse is assessing the patient and collecting only the most important information. Why type of assessment is the nurse doing? a. Focused b. Functional c. Emergency d. Comprehensive .
70. A patient has sustained an injury to the cerebellum. Which area would be the primary area for assessment? a. Vital signs b. Neurologic system c. Cardiac function d. Coordination .
71. The nurse assesses brisk reflex in a patient. The nurse would document this finding as which of the following? a. 3+ b. 1+ c. 2+ d. 5+ .
72. When chartering it is the nurse legal mandate to record both normal and abnormal assessment data and the correct time. a. True b. False.
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