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WorksheetsHEALTH EXAM 1
Total questions: 50
Worksheet time: 2hrs 40mins
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and is in the clinic to start prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be the MOST accurate? The woman is:
excited about her pregnancy but nervous about the labor
exhibiting verbal and nonverbal behaviors that do not match
excited about her pregnancy, but her husband is not and this is upsetting to her
not excited about her pregnancy but believes the nurse will negatively respond to her if she states this
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
well-adjusted adolescent who came in for a sports physical
recovering alcoholic who came in for a basic physical exam
man whose wife has just been diagnosed with lung cancer
man with a hearing impairment who uses sign language to communicate and who has an interpreter with him
The nurse makes which adjustment in the physical environment to promote the success of an interview?
reduces noise by turning off televisions and radios
reduces the distance between the interviewer and patient to 2 ft or less
provides a dim light that makes the room cozy and helps the patient relax
arranges seating across a desk/table to allow the patient some personal space
In an interview, the nurse may find it necessary to take notes to aid their memory later. Which statement is true regarding note-taking?
it may impede the nurses observation of the patient's nonverbal behaviors
it allows the patient to continue at their pace as the nurse records what is said
it allows the nurse to shift attention away from the patient, resulting in an increased comfort level
it allows the nurse to break eye contact with the patient, which may increase their level of comfort
The nurse asks, "I would like to ask you to some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the ___ phase of the interview process.
summary
closing
body
opening/introduction
A woman has just entered the ER after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
Hello, 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. How are you?
Mrs. H, my name is Mrs. C. I'll need to ask you a few questions about what happened.
During an interview, the nurse states, "you mentioned having shortness of breath. Tell me more about that." Which verbal skill is used with this statement?
reflection
facilitation
direct question
open ended question
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
Mr. Y, at your age, surely you have been hospitalized before?
Mr. Y, I just need permission to get your medical records from County Medical
Mr. Y, you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?
Mr. Y, I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior?
be silent, and allow him to continue when he is ready
smile at him and say "don't worry about all of this. I'm sure we can find out why you're having these pains"
lean back in the chair and ask, "You are looking at me kind of funny; there isn't anything wrong, is there?"
stand up and say "I can see that this interview is uncomfortable for you. We can continue it another time"
A woman is discussing the problems she is having with her 2 year old son. She says, "he won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurses best verbal response would be:
"go on, I'm listening"
"Fits? Tell me what you mean by this"
"Yes, it can be upsetting when a child has a fit"
"Don't be upset when he has a fit; every 2 year old has fits"
When performing a physical assessment, the first technique the nurse will always use is
palpation
inspection
percussion
auscultation
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
usually yields little information
takes time and reveals a surprising amount of info
may be somewhat uncomfortable for the expert practioner
requires a quick glance at the patient's body systems before proceeding with palpation
The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to assess the patients skin temperature?
fingertips; they are more sensitive to small changes in temperature
dorsal surface of the hand; the skin is thinner on this surface than on the palms
ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity
palmar surface of the hand; this surface is most sensitive to temperature variations b/c of its increased nerve supply in this area
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
palpation
inspection
percussion
auscultation
The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?
palpation of reportedly tender areas are avoided b/c palpation in these areas might cause pain
palpating a tender area is quickly performed to avoid any discomfort that the patient may experience
the assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths
the assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed?
percussing one over each area
quickly lifting the striking finger after each stroke
striking with the fingertip, not the finger pad
using the wrist to make the strikes, not the arm
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
consider this a normal finding
palpate this area for an underlying mass
reposition the hands, and attempt to percuss in this area again
consider this finding as abnormal, and refer the patient for additional treatment
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
slope of the earpieces should point posteriorly
although the stethoscope doesn't magnify sound, it does block out extra room noise
fit and quality of the stethoscope aren't as important as its ability to magnify sound
ideal tubing length should be 22 inches to dampen the distortion of sound
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:
is used to listen for high pitched sounds
is used to listen for low pitched sounds
should be lightly held against the persons skin to block out low pitched sounds
should be lightly held against the persons skin to listen for extra heart sounds and murmurs
During auscultation of a patients heart sounds, the nurse hears an unfamiliar sound. The nurse should:
document the findings in the patients record
wait 10 minutes, and auscultate the sound again
ask the patient how they are feeling
ask another nurse to double check the finding
The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?
learned through language acquisition and socialization
genetically determined on the basis of racial background
a nonspecific phenomenon and is adaptive but unnecessary
biologically determined on the basis of physical characteristics
During an assessment, the nurse notices that a patient is handing a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?
ask the patient about the item and its significance
ask the patient to lock the item with other valuables in the safe
tell the patient that a family member should take the valuables home
no action is necessary
The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?
belief in and worship of God or gods
being closely tied to one's ethnic background
attendance at a specific church or place of worship
a connection with something larger than oneself and belief in transcendence
The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?
"Do you smoke?"
"What is your religion?"
"Do you have a history of heart disease?"
"How many years have you lived in the United States?"
Symptoms, such as pain, are often influenced by a person's cultural heritage. Which of the following is a true statement regarding pain?
nurses' attitudes toward their patients pain are unrelated to their own experiences with pain
nurses need to recognize that many cultures practice silent suffering as a response to pain
a nurses' area of clinical practice will most likely determine their assessment of a person's pain
a nurses' years of experience and current position are strong indicators of their response to patient pain
During a class on cultural practices, the nurse hears the term "cultural taboo". Which statement illustrates the concept of a cultural taboo?
trying prayer before seeking medical help
believing that illness is a punishment of sin
refusing to accept blood products as part of treatment
stating that a child's birth defect is the result of the parent's sins
The nurse is performing a general survey. Which action is a component of the general survey?
observing the patient's body stature and nutritional status
interpreting the subjective information the patient has reported
measuring the patient's temperature, pulse, respirations, and blood pressure
observing specific body systems while performing the physical assessment
When assessing an older adult, which vital sign changes occur with aging?
increase in pulse rate
widened pulse pressure
increase in body temperature
decrease in diastolic blood pressure
After completing an initial assessment of a patient, the nurse charted that his respirations are eupneic and his pulse is 58 BPM. These types of data would be:
subjective
objective
introspective
reflective
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem?
patient with post op pain
newly diagnosed patient with diabetes who needs diabetic teaching
individual with a small laceration on the sole of the foot
individual with shortness of breath and respiratory distress
When considering priority setting of problems, the nurse keeps in mind that second level priority problems include which of these aspects?
low self-esteem
lack of knowledge
abnormal lab values
severely abnormal vital signs
Which critical thinking skill helps the nurse see relationships among the data?
validation
clustering related cues
identifying gaps in data
distinguishing relevant from irrelevant
A newly admitted patient is in acute pain, hasn't been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
breathing, pain, sleep
breathing, sleep, pain
sleep, breathing, pain
sleep, pain, breathing
What step of the nursing process includes data collection by health history, physical examination, and interview?
planning
diagnosis
evaluation
assessment
As a mandatory reporter of elder abuse, which must be present before a nurse should notify the authorities?
statements from the victim
statements from witnesses
proof of abuse/neglect
suspicion of abuse/neglect
Which term refers to a wound produced by the tearing/splitting of body tissue, usually from blunt impact over a bony surface?
abrasion
contusion
laceration
hematoma
The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide. Which of these statements best describe it's use?
the DA tool is to be administered by law enforcement personnel
the DA tool should be used in every assessment of suspected abuse
the # of yes answers indicate the woman's understanding of her situation
the higher # of yes answers, the more serious the danger of the situation
The nurse suspects abuse when a 10 year old child is taken to the urgent care for a leg injury. The best way to document the history and physical findings is to:
document what the childs caregiver tells the nurse
use the words the child has said to describe how the injury occurred
record what the nurse observes during the conversation
rely on the photographs of the injuries
The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
to provide an opportunity for interaction between the patient and nurse
to provide a form for obtaining the patients biographic info
to document the normal/abnormal findings of a physical assessment
to provide a database of subjective/objective info about the patients past and current health
The nurse is assessing the vital signs of a 20 year old male marathon runner and documents the following vitals: temperature 97 degrees, pulse 48, respirations 14, BP 104/68. Which statement is true concerning these results?
patient is experiencing tachycardia
normal vitals for a healthy, athletic adult
patients pulse rate is not normal and physician should be notified
patient should return to the clinic in 1 week
A patient's blood pressure is 118/82 mm hg. He asks the nurse, "what do these numbers mean?" The nurses best reply is:
the numbers are within normal range and nothing to worry about
bottom number is diastolic and reflects the stroke volume of the heart
top number is systolic BP and reflects the pressure of the blood against the arteries when the heart contracts
concept of blood pressure is difficult to understand and the primary thing to be concerned about is the top number
While measuring a patients blood pressure, the nurse recalls that certain factors, such as ___, help determine blood pressure
pulse rate
pulse pressure
vascular output
peripheral vascular resistance
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
more clearly hear Korotkoff sounds
detect the presence of an auscultatory gap
avoid missing a falsely elevated blood pressure
more readily identify phase IV of the Korotkoff sounds
During an assessment, which part of the hand is best for detecting vibration?
fingertips
index finger and thumb in opposition
dorsum of the hand
ulnar surface of the hand
The best description of the pitch of a sound wave obtained by percussion is:
intensity of the sound
number of vibrations per second
length of time the note lingers
the overtones of the note
Which is a forensic term that is related to "purpura" but is not related to blunt force trauma?
wound
incision
ecchymosis
bruise
During an interview, a woman has answered "yes" to 3 of the Abuse Assessment Screen questions. How should you proceed?
ask the patient if she has filed a restraining order
proceed by asking more questions about the items she answered "yes"
respond by confirming that the patient was abused
interview the woman's partner and compare notes
Which is an appropriate recording of a patient's reason for seeking health care?
angina pectoris, duration 2 hours
substernal pain radiating to left axilla, 1 hour duration
"grabbing" chest pain for 2 hours
Pleurisy, 2 days duration
The statement "reason for seeking care" has replaced the "chief complaint". This change is significant because:
the chief complaint is a diagnostic statement
the newer term allows another individual to supply necessary info
the newer term incorporates wellness needs
the reason for seeking care can incorporate the history of the present illness
Which factor is identified as a priority influence on a patient's health status?
poverty
lifestyle factors
legislative action
occupational status
