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NURS 303 Quiz 1
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission? A. A comprehensive assessment B. A problem-based health assessment C. An episodic assessment D. A screening assessment for colorectal cancer - correct answer A. A comprehensive Assessment After collecting data, the nurse begins data analysis with which activity? A. Documenting information from the history B. Organizing the data collected C. reporting data to other care providers D. Recording data from the physical examination - correct answer B. Organizing the data collected Which situation illustrates a screening assessment? A. A patient visits a clinic for the first time and the nurse completes a history and physical examination B. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels C. A nurse at an urgent care center checks the blood pressure, pulse, temperature, and respirations of a patient reporting leg pain D. A patient with diabetes mellitus comes to the laboratory to get her blood glucose tested prior to a visit with a healthcare provider - correct answer B. A hospital sponsors a health fair in a community to measure blood pressure as well as cholesterol levels The nurse documents which information in the patient history? A. the patient is scratching his left arm B. The patient's skin feels warm C. The patient reports itching of her eyes D. the patients temperature is 100 - correct answer C. The patient reports itching of her eyes Select the example given below that represents information a nurse collects from a patient during a physical examination. A. Shiny skin and lack of hair found on lower legs B. concerned about lack of money to pay for prescriptions C. Complains of tinging in both feet while sleeping D. Family history of colon and breast cancer - correct answer A. Shiny skin and lack of hair found on lower legs
The nurse is administering an influenza (flu) shot to a patient in a retail health setting. Of which level of prevention is this an example? A. Primary B. Secondary C. Post-secondary D. Tertiary - correct answer A. Primary A patient complains of a cough for 4 days unrelieved with position changes. The nurse interprets this as a symptom and documents the finding under ___ on the patients chart. A. the nursing care plan B. assessment C. history D. vital signs - correct answer C. History The _____ refers to the circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to physical, psychological, or socioeconomic circumstances, or the expertise of the nurse. A. body systems assessment B. nursing process C. health promotion interventions D. context of care - correct answer D. Context of Care The nurse is assessing the patient for the first time in the outpatient diabetic clinic. A ____ type of health assessment would be the most appropriate for this visit. A. focused assessment B. episodic follow-up assessment C. shift assessment D. comprehensive health assessment - correct answer D. Comprehensive health assessment A patient tells the nurse that he has had a headache and nausea for 3 days. Which type of assessment should the nurse perform? A. Focused assessment B. episodic follow-up assessment C. shift assessment D. comprehensive health assessment - correct answer A. Focused Assessment The nurse is incorporating the principles of the quality and safety competencies from the Institute of Medicine (IOM) recommendations into the health assessment of a patient in the long-term care setting. What principles should the nurse consider? (SETA) A. Use evidence to support interventions B. Evaluate the plan of care. C. Use a step-by-step approach to problem-solving.
G. Documentation of data - correct answer A. Collection of objective data B. Collection of subjective data E. Analysis of Data F. Physical Exam The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? A. How often do you visit the medicine man for your health care? B. Tell me about your health care beliefs and practices. C. Many Navajo people are afraid of hospitals. Are you afraid? D. Have you ever had a physical examination with a physician or a nurse practitioner? - correct answer B. Tell me about your health care beliefs and practices The nurse is conducting an interview with Jeremy, a 17-year-old accompanied by his mother. Which statement made by the nurse is an age-appropriate adjustment when conducting a health history with an adolescent? A. Jeremy, do you have a girlfriend, and if so are you sexually active yet? B. Mrs. Williams, is your son sexually active yet? C. Jeremy, how do you incorporate safe sex practices into your daily life? D. Mrs. Williams, would you wait outside while I discuss a few things with Jeremy? - correct answer D. Mrs. Williams, would you wait outside while I discuss a few things with Jeremy? During an interview, an elderly patient tells the nurse that she has periodic problems keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom analysis is the nurse pursuing with this question? A. Severity B. Freuqency C. Aggravating factors D. Location - correct answer C. Aggravating factors Which communication technique conveys genuine interest in what the patient has to say? A. Active listening B. Siting close to the patient C. Maintaining professional dress and conduct D. holding the patients hand during the interview - correct answer A. Active Listening A 62-year-old patient tells the nurse that he is in excellent health and does not take any medications. What is the most appropriate response by the nurse to follow up on the patients statement? A. Do you avoid taking drugs because of bad experiences? B. Which medications have you taken in the past? C. That is hard to believe. Most men you age take medications.
D. Do you use over-the-counter medications or herbal preparations? - correct answer D. Do you use over-the-counter medications or herbal preparations? The nurse is focusing the interview for a patient who complains of headaches and nausea. Which interview format is based on body function as opposed to body system? A. Review of systems B. Functional health patterns C. Health perception database D. Nursing process - correct answer B. Functional health patterns The nurse knows that the single most important factor in conducting an interview is the communication process. Which factors will most likely affect a positive interview process and therapeutic communication? (SETA) A. Obtaining the patient's history B. Maintaining privacy C. Asking open-ended questions D. Conducting a fast, efficient interview E. Obtaining answer to questions in advance F. Asking closed-ended questions G. Asking how the patient is feeling today - correct answer B. Maintaining privacy C. Asking open-ended questions G. Asking how the patient is feeling today The nurse is conducting an interview. During an interview, the primary type of data being collected is: A. subjective data. B. objective data. C. secondary data. D. recent data. - correct answer A. Subjective data In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the __. A. history of present illness B. biographic data C. present health status D. review of symptoms - correct answer A. History of present illness After the nurse has completed the interview, a symptom analysis is performed to derive appropriate interventions. What is the best description of symptom analysis? A. A way to document a comprehensive interview B. A method of collecting data about a patient's past medical history C. A systematic collection of subjective data related to the patient's chief complaint
D. Suggest that the teen see a health care provider because the axle grease will infect the boil. - correct answer B. Ask the teen what the boil looks like and feels like and if the axle grease is healing the boil. A nurse is caring for a woman who has just been pronounced dead. Her adult children are in the room. Which statement by the nurse indicates culturally competent care? A. Which funeral home would you like notified of your mother's death? B. We will be moving her to the morgue in about 30 minutes. C. Would you like some time alone with your mother for any specific ceremonies? D. Here are some of her personal belongings that were in the drawer. - correct answer C. Would you like some time alone with your mother for any specific ceremonies? A nurse is assessing a woman whose religious beliefs do not allow blood transfusions. She has severe anemia, is very weak, and has altered mental status. What should the nurse do to provide culturally competent care? A. Examine his or her feelings about the role of religious beliefs in making decisions about life. B. Recognize that he or she cannot provide care to patients whose religious beliefs endanger their life. C. Try to convince the patient to have a blood transfusion to save her own life. D. Determine whether the patient is competent to make her own decisions about health care. - correct answer A. Examine his or her feelings about the role of religious beliefs in making decisions about life. A nurse is teaching a family from Guatemala about the importance of exercise to reduce body weight. The husband asks, "what exercise should we do?" Considering the time orientation of this family, what is the most effective way for the nurse to respond? A. Research has shown that walking 30 minutes most days of the week is best. B. Is there an exercise that you can do today for 30 minutes and add it to your daily routine? C. If you exercise 30 minutes most days of the week, you can lose weight by your next visit. D. I have always found that resistance weight training each day for 30 minutes is effective. - correct answer B. Is there an exercise that you can do today for 30 minutes and add it to your daily routine? An older man who is near death has been admitted to the hospital, and his family members are at his bedside. Which questions or statement should the nurse use during the admission assessment to address the spiritual needs of the patient and his family appropriately? A. What is your religion? I'll make the appropriate spiritual arrangements. B. Tell me what death means to people from your culture. C.Are there any special needs that you and you family request at this time? D. I'll call the hospital priest so he can administer last rites. - correct answer C. Are there any special needs that you and your family request at this time? __ refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status. A. Discrimination
B. Spirituality C. Culture sensitivity D. Diversity - correct answer D. Diversity What standards or guidelines exist to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the United States? A. Each ethnic group has its own written standards for competent cultural care. B. There are no standards or guidelines for giving competent cultural care. C. The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. D. The American Society of Cultural Competence has guidelines containing the health beliefs and practices of major cultural groups. - correct answer C. The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. The nurse is performing a cultural assessment for an immigrant from Mexico. The patient is having difficulty adapting to the American health system. What is the most likely explanation for this problem? A. Culture shock B. Cultural taboos C. Cultural unfamiliarity D. Culture disorientation - correct answer A. Culture shock An elderly African-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse should: A. perform a physical examination. B. recognize and accept different beliefs about health. C. identify high-risk patients for various diseases. D. apply statistical trends of various ethnic and cultural groups. - correct answer B. recognize and accept different beliefs about health The nurse is assessing a patient's spiritual beliefs and practices. Which questions should be considered part of the assessment? (SETA) A. What type of spiritual/religious support do you desire? B. What is the name of your clergy, ministers, chaplains, pastor, rabbi? C. What does pain mean to you? D. What does dying mean to you? E. What are your educational goals? F. Do you use prayer in your life? - correct answer A. What type of spiritual/religious support do you desire? B. What is the name of your clergy, ministers, chaplains, pastor, rabbi? D. What does dying mean to you? F. Do you use prayer in your life?
Which question is appropriate for a nurse to ask at the beginning of a mental health history? A. Have you been feeling anxious or sad? B. How have you been feeling about yourself? C. Are you alone a lot, or do you socialize with friends? D. How are you dealing with the stressors in your life? - correct answer B. How have you been feeling about yourself? During a history the patient says that she is so uncomfortable with her life that she wishes that it were over. Which is an appropriate follow-up questions from the nurse? A. Have you thought about hurting yourself? B. Oh, I've felt that way many times. C. That feeling will go away, just give it some time. D. In which ways has your life been uncomfortable? - correct answer A. Have you thought about hurting yourself? During a health history a patient says, "Stressors? Oh, yeah, I have stressors. I got a promotion at work; and, with the extra income I'm going to move into a new house, but that has been delayed because my mother is in the hospital and my son is going off to college. To get through this time I just keep using my support systems, exercising, and meditating." How does the nurse interpret these comments by the patient? A. Flight of ideas B. Moderate Anxiety C. Positive coping strategies D. Rationalization and denial - correct answer C. Positive coping strategies Which techniques does a nurse use to assess the mental status of patients? A. Ask them about any of their relatives who have mental health disorders B. Have them calculate the change to expect after making a purchase C. Ask them to recall how they cope with stress on a daily basis D. Have them describe the moods and emotions they experience on a usual day. - correct answer B. Have them calculate the change to expect after making a purchase During a sports physical of a 16-year-old girl, the nurse asks which questions to collect data about drug use? A. Many teenagers have tried street drugs. Have you tried any? B. Tell me which street drugs your friends have offered you. C. Do your friends tell you about the street drugs they use? D. Your high school has a reputation for students using street drugs. Do you use these drugs? - correct answer A. Many teenagers have tried street drugs. Have you tried any? A patient reports nausea and vomiting; and the nurse observes hand tremors, agitation, and sweating. In view of these findings, which additional data would the nurse need to collect?
A. Which fears or stressors the patient has been experiencing. B. When the patient last took illegal drugs and which ones were taken. C. Which kinds of obsessions or compulsions the patient has been experiencing. D. When the patient last drank alcohol and how much was consumed. - correct answer D. When the patient last drank alcohol and how much was consumed. The nurse notices that a patient has difficulty separating relevant from irrelevant information during a conversation. This patient is having difficulty with: A. circumstantiality. B. neologism. C. blocking. D. flight of ideas. - correct answer A. Circumstantiality The nurse is obtaining the mental health history of a new patient. What should the nurse include in the mental health history? (SETA) A. The patient's description of self B. A past medical history C. The current medications the patient is taking D. Cultural beliefs E. Spiritual beliefs - correct answer A. The patient's description of self B. A past medical history C. The current medications the patient is taking The nurse is planning to teach a group of patients stress reduction exercises to reduce the risk of depression. Which population group is at highest risk for depression? A. Males B. School-age children C. Adolescents D. Individuals starting new careers - correct answer C. Adolescents An insufficient amount of the neurotransmitter GABA may result in __. A. depression B. hallucinations C. delusions D. anxiety - correct answer D. Anxiety The nurse is caring for a patient in the mental health facility who has a diagnosis of bipolar disorder. The nurse knows that this is because mental health is directly affected by the: A. cerebral spinal fluid. B. neurotransmitters. C. thickness of the dura mater.
The nurse obtains vital signs on a 42-year-old man having his annual physical examination. He has no medical conditions and states that his health is excellent. Using an automated blood pressure device, his blood pressure is measured as 62/40. Which action by the nurse is most appropriate. A. Obtain a different cuff and take the blood pressure again. B. Take the blood pressure again using the auscultation method. C. Place the patient in a supine position and take the pressure on the leg. D. Record the blood pressure and continue with the examination. - correct answer B. Take the blood pressure again using the auscultation method. Which set of vital signs should the nurse recognize as out of the expected range? A. 42-year-old man: BP: 114/82; pulse: 74; respiration: 16, temperature: 36. B. 11-year-old girl: pulse: 88, respiration: 22, temperature: 36. C. 3-year-old boy: pulse: 130, respiration: 44, temperature: 36. D: 1-month-old girl: pulse: 120, respiration: 42, temperature: 36.7 - correct answer C. 3-year-old boy: pulse: 130, respiration: 44, temperature: 36. The nurse records the following general inspection findings on a patient: 41-year-old Hispanic male in no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than stated age. Patient with flat affect and makes minimal eye contact. What additional information should be added to this general inspection? A. His body movement B. The family history C. The estimated size of his liver D. His pulse rate - correct answer A. His body movement A patient is brought to the emergency department in severe respiratory distress. Which method of temperature measurement would be the most appropriate? A. Oral temperature B. Axillary temperature C. Temporal artery D. Rectal temperature - correct answer C. Temporal artery A 62-year-old patient tells the nurse that he has recently had frequent fainting spells. After palpating the radial pulse, 13 pulsations are counted in 15 seconds with a regularly irregular rhythm. What is the most appropriate action for the nurse at this time? A. Reassess the pulse rate after he walks around the room for several minutes B. Reassess the pulse rate for 15 seconds using the carotid artery C. Take an apical pulse for 5 full minutes, counting the number of skipped beats D. Palpate the pulse for one minute and determine the pattern of irregularity. - correct answer D. Palpate the pulse for one minute and determine the pattern of irregularity. The nurse is counting an infant's respirations. Which technique is correct? A. Watch the chest rise and fall.
B. Watch the abdomen for movement. C. Place a hand across the infant's chest. D. Use a stethoscope to listen to the breath sounds. - correct answer B. Watch the abdomen for movement. The nurse is obtaining a pulse oximeter reading on an adult patient. Where is the probe of a pulse oximeter placed? A. In the mouth or under the arm B. On the ear C. On the tip of a finger or toe or on an ear lobe D. In the rectum - correct answer C. On the tip of a finger or toe or on an ear lobe The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient: A. defer temperature for this age group B. oral C. rectal D. tympanic - correct answer D. Tympanic The student nurse is learning how to obtain blood pressures and is studying what factors can affect blood pressure. What should the student nurse include as factors that affect blood pressure? (SETA) A. What the person ate B. Smoking C. Mobility D. Race E. Gender F. Weight G. Pain - correct answer B. Smoking D. Race E. Gender F. Weight G. Pain An adult patient is being assessed in the outpatient clinic secondary to a recent weight loss. Why is the weight of an adult patient measured routinely during a physical assessment? A. It allows assessment of body fat content. B. A change in body weight can be indicative of health problems. C. Fat deposits in specific locations can be identified. D. It identifies patients who exercise and those who do not exercise. - correct answer B. A change in body weight can be indicative of health problems.
D. Report by the patient describing the pain experienced - correct answer D. Report by the patient describing the pain experienced A patient had a knee replaced of arthritis. He reports that he has not slept well for several nights. He states that he can't get comfortable. Today he is asking for pain medication more often. What could be a reason for this increase in pain? A. Arthritis pain is variable; it can be mild one day and severe the next B. Pain tolerance decreases with sleep deprivation C. The anesthesia from surgery is wearing off D. The patient is using the pain medication to help him sleep during the day - correct answer B. Pain tolerance decreases with sleep deprivation A patient complains of chest pain. Which question has the highest priority to obtain additional information? A. What were you doing when the pain first occurred? B. Do you have shortness of breath with the chest pain? C. What does the pain feel like? D. Has anyone in your family ever had similar pain? - correct answer C. What does the pain feel like? A patient complains of leg pain. Which question is pertinent to ask to gain additional information? A. What were you doing when the pain first occurred? B. How do you feel about having this pain? C. Do you think the pain is caused by a cramp? D. Has anyone in your family ever had similar pain? - correct answer A. What were you doing when the pain first occurred? A female has been admitted to the emergency department with severe abdominal pain. She is lying on a stretcher quietly, with very little movement. Which patient response should the nurse anticipate when palpating this patient's abdomen? A. Flushing of the face and neck B. Guarding over the abdomen C. Redness on the lower abdominal quadrants D. Decreased peristalsis - correct answer B. Guarding over the abdomen The nurse is attending an in-service on pain management for postoperative patients. Which statement regarding pain is true? (SETA) A. An individual's pain response is predictable based on his or her culture or ethnicity. B. Individuals from all cultures respond to pain similarly. C. The pain response may be influenced by one's culture. D. Individuals may express pain differently. E. Pain management may vary depending on the source of pain. - correct answer C. The pain response may be influenced by one's culture.
D. Individuals may express pain differently. E. Pain management may vary depending on the source of pain. The nurse is performing a pain assessment of a 4-year-old toddler. Which pain assessment scale would be best for this patient? A. Visual Analog Scale B. Numeric Pain Intensity Scale C. Wong/Baker Faces Rating Scale D. Pain Intensity Scale - correct answer C. Wong/Baker Faces Rating Scale The nurse is reviewing the pathophysiology of pain. Where does the perception of pain actually occur? A. The dorsal horn of the spinal cord B. The parietal lobe of the cerebral cortex C. The afferent (sensory) nerves D. The visceral and somatic free nerve endings (nociceptors) - correct answer B. The parietal lobe of the cerebral cortex The nurse is assessing for objective findings are associated with the patient's pain level. Which findings are commonly associated with acute pain? (SETA) A. The patient is crying B. An elevated blood pressure C. An elevated heart rate D. Diaphoresis E. The patient states a pain level of 8 out of 10 on pain scale F. Vital signs stable - correct answer B. An elevated blood pressure C. An elevated heart rate D. Diaphoresis The nurse is compelled to address and manage a patient's pain level by which ethical principles? (SETA) A. Beneficence B. Liberty C. Autonomy D. Nonmaleficence E. Justice - correct answer A. Beneficence D. Nonmaleficence The nurse is assessing the degree of pain or discomfort a patient is feeling. The nurse knows that this will be dependent primarily on: A. ability to explain the pain or discomfort.
