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Worksheetsunit 1 health assessment exam
Total questions: 161
Worksheet time: 2hrs 25mins
The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?
Learn through language acquisition and socialization
Genetically determined on the basis of racial background
A non specific phenomenon and is adaptive but unnecessary
Biologically determined on the basis of physical characteristics
During a class on the aspects of culture the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of the characteristics of culture?
static and unchanging
members share similar physical characteristics
Members share a common geographic origin and religion
Adapted to specific conditions related to environmental and technical factors
During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating "the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society" reflects which term?
Norms
Culture
Ethnicity
Assimilation
The nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture?
Fitting as many people as possible into the majority culture
Identifying small groups of people who do not want to be identified within the larger culture
Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations
Recognizing groups of people within a culture with shared characteristics that are not common to all members of the culture
When reviewing the demographics of ethnic groups in the United States the nurse recalls that which is the largest and fastest growing population?
Asian
hispanic
American Indian
African American
During an assessment the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. which action by the nurse is appropriate?
I ask the patient about the item and its significance
Ask the patient to lock the item with other valuables in the hospital safe
Tell the patient that a family member should take valuables home
No action is necessary
After a class on culture and ethnicity the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
ethnicity is dynamic and ever changing
Ethnicity is the belief in a higher power
Ethnicity pertains to a social group that may possess shared traits such as religion and language
Ethnicity is learned from birth through the process of language acquisition and socialization
The nurse is comparing the concepts of religion and spirituality. Which statement best describes an appropriate component of one's spirituality?
Belief in and the 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
A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?
integration
Assimilation
Biculturalism
Heritage consistency
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 any history of heart disease
How many years have you lived in the United States
The nurse is reviewing theories of illness. The germ theory which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions is a basic belief of which theory?
Holistic
Biomedical
Naturalistic
Magicoreligious
An Asian American woman is experiencing diarrhea, which is believed to be "cold" or "yin". What should the nurse recognize that the woman may likely try to treat it?
Foods that are hot or Yang
Readings and Eastern medicine meditations
High doses of medicines believed to be cold
No treatment because diarrhea is an expected part of life
Many Asians believe in the yin and Yang theory which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects the philosophy's view of health?
A person is able to work and produce
A person is happy stable and feels good
All aspects of the person are in perfect balance
A person is able to care for others and function socially
The statement that illness is caused by an imbalance or disharmony in the forces of nature most accurately reflects the views about illness from which theory?
germ theory
Naturalistic theory
Magicoreligious theory
Biomedical or scientific theory
What does an individual who believes in the magicoreligious theory of illness and disease believe is the cause of illness?
Germs and viruses
Supernatural forces
Eating imbalanced foods (cold/hot)
Imbalance within his or her spiritual nature
What should the nurse who is caring for an American Indian woman seeking help to regulate her diabetes anticipate or expect of the patient?
Will comply with the treatment prescribed
Has given up her belief in naturalistic cause of disease
May also be seeking the assistance of a shaman or medicine man
Will need extra help in dealing with her illness and may be experiencing a crisis of faith
During a class on religion and spirituality the nurses asked to define spirituality. Which statement by the nurse best describes spirituality?
Is a personal search to discover a supreme being
Is an organized system of beliefs concerning the cause nature and purpose of the universe
It is a belief that each person exists forever in some form such as a belief in reincarnation or the afterlife
Focuses on a connection with something bigger than oneself and a belief in transcendence
When caring for children with a different cultural perspective what would the nurse recognize may pose a challenge?
Children have spiritual needs that are influenced by their stages of development
Children have spiritual needs that are direct reflections of what is occurring in their homes
Religious beliefs rarely affect the parents perception of the illness
Parents are often the decision makers and they have no knowledge of their children's spiritual needs
A 30 year old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit with the woman's sister the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. What is this woman likely experiencing?
Cultural shock
Cultural taboos
Cultural unfamiliarity
Cultural disorientation
After a symptom is recognized the first effort at treatment is often self treatment. Which of the following statements is true about self treatment?
Not recognized as valued by most health care providers
Usually ineffective and may delay more effective treatments
Always less expensive than biomedical alternatives
Influenced by the accessibility of over the counter medicines
The nurse is reviewing the hot/cold theory of health and illness. Which statement 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 connectedness, 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
When providing culturally competent care nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
Are you of the Christian faith
Do you want to see a medicine man
How often do you seek help from medical providers
What cultural or spiritual beliefs are important to you
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 a part of treatment
Stating that a child's birth defect is the result of the parent's sins
The nurse should recognize that categories such as ethnicity, gender, and religion illustrate which concept?
family
Cultures
Spirituality
Subcultures
The nurse is reviewing concepts related to one's heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe?
Culture
religion
ethnicity
Spirituality
When planning a cultural assessment the nurse should include which component?
family history
Chief complaint
Medical history
Health practices
The nurse is asking questions about a patients health beliefs. Which questions are appropriate?
What is your definition of health
Does your family have a history of cancer
How do you describe illness
Have you ever had any surgeries
How do you keep yourself healthy
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic today to begin 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 most accurate when describing this woman.
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 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 examination
A man who came in with his wife who was chest diagnosed with lung cancer
Man with a hearing impairment who has an interpreter with him who came in for a follow up blood pressure check
Which adjustment in the physical environment will the nurse make to promote the success of an interview?
Arrange sheeting across a desk or table
Reduce noise by turning off televisions and radios
Reduce the distance between the interviewer and the patient to two feet or less
Provide dim lighting to make the room cozy and help the patient relax
In an interview the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note taking?
Note taking may impede the nurse's observation of the patient's nonverbal behaviors
Note taking allows the patient to continue at their own pace as the nurse records what is said
Note taking allows the nurse to shift attention away from the patient resulting in an increased comfort level
Note taking allows the nurse to break eye contact with the patient which may increase his or her level of comfort
The nurse asks, "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." Based on this question the nurse is at which phase of the interview process.
Summary
Closing
Working
Opening or introduction
A woman has just entered the emergency department 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 Nurse C
Mrs H My name is Nurse C how are you
Hello missus H my name is Nurse C it sure is cold today
Mrs H my name is Nurse 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 for 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 this data
Mr Y at your age surely you have been hospitalized before
Mr YI just need permission to get your medical records from County medical
Mr White you mentioned that you have been hospitalized on several occasions would you tell me more about that
Mr YI just need to get some additional information about your past hospitalization. when was the last time you were admitted for chest pain
In using verbal responses to assist the patients narrative some responses focus on the patients frame of reference and some focus on the health care providers perspective. Which type of verbal response focuses on the health care provider's perspective?
empathy
Reflection
Facilitation
Confrontation
When taking a history from a newly admitted patient the nurse notices that the patient often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior
Lean forward slightly and make eye contact asking is there anything else
smile at him and say don't worry abou....an get to the bottom of your symptoms
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 two 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." Which is the best response by the nurse to gain a better understanding of the problem?
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 two year old has fits
A 17 year old single mother is describing how difficult it is to raise a three year old child by herself. During the course of the interview she states "I can't believe my boyfriend left me to do this by myself. What a terrible thing to do to me." Which of these responses by the nurse uses empathy?
You feel alone
I can't believe he left you alone
It must be so hard to care for a child all alone
I would be angry too raising a child alone is no picnic
The nurse has used interpretation regarding a patient's statement or actions. What should the nurse do after using this technique?
Apologize because using interpretation can be demeaning for the patient
Allow time for the patient to confirm or correct the inference
Continue with the interview as though nothing has happened
Immediately restate the nurse's conclusion on the basis of the patient's nonverbal response
During an interview a woman says, "I have decided that I can no longer allow my children to live with their father's violence but I just can't seem to leave him." Using interpretation which would be the best response by the nurse?
You are going to leave him?
If you are afraid for your children then why can't you leave
It sounds as if you might be afraid of how your husband will respond
It sounds as though you have major decision I think it is a good one
A pregnant woman states, "I just know labor will be so painful that I won't be able to stand it. I know it sounds awful but I really dread going into labor." The nurse responds by stating, "oh don't worry about labor so much. I have been through it and although it is painful many good medications are available to decrease the pain." which statement is true regarding the nurse's response?
Therapeutic response sharing something personal the nurse gives hope to this woman.
Non therapeutic response by providing false reassurance the nurse actually cut off further discussion of the woman's fears.
therapeutic response By providing information about the medication available the nurse is giving information to the woman.
Non therapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication
During a visit to the clinic 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?" What is the most appropriate response by the nurse?
I'd quit if I were you the doctor really knows what he is talking about
Would you like some information about the different ways a person can quit smoking
Stopping I understand how you feel 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
As the nurse enters a patient's room the nurse finds the patient crying. The patient states that she has just found out that the lump in her breast is cancer and putting her hand over her breast says, "I'm so afraid of, um, you know." which would be the most therapeutic response by the nurse when said in a gentle manner?
You're afraid you might lose your breasts
No I'm not sure what you're talking about
I'll wait here until you get yourself under control then we can talk
I can see that you are very upset perhaps we should discuss this later
A nurse is taking complete health histories on all the patients attending a Wellness workshop. On the history form one of the written questions asks, " You don't smoke drink or take drugs do you? This is an example of what type of question?
Talking too much
Using biased or leading questions
Using blunt language to deal with Distasteful topics
When observing a patient's verbal and nonverbal communication the nurse notices a discrepancy. What action should the nurse take in this situation?
Ask someone who knows the patient well to help interpret this discrepancy
Focus on the patients verbal message and try to ignore the nonverbal behaviors
Try to integrate the verbal and nonverbal messages and then interpret them as an average
Focus on the patients nonverbal behaviors because they are often more reflective of the patient's true feelings
During an interview a parent of a hospitalized child is sitting in a recliner with his legs extended and his arms at his sides. As the interviewer begins to discuss his son's treatment he suddenly changes positions and crosses his harms against his chest and crosses his legs. What does this change in posture suggest?
simply Changing positions
More comfortable in this position
Tired and needs a break from the interview
Uncomfortable talking about his son's treatment
A mother brings her 28 month old daughter into the clinic for a well child visit. At the beginning of the visit the nurse focuses attention away from the toddler but as the interview progresses the toddler begins to warm up in a smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
Tickle the toddler and get her to laugh
Stoop down to her level and ask her about the toy she is holding
Continue to ignore her until it is time for the physical exam
Ask the mother to leave during the examination of the toddler because toddlers often fuss less if their parent is not in view
During an examination of a preschool child the nurse will need to take the child's blood pressure. What would the nurse do to try to gain the child's full cooperation?
Tell the child that the blood pressure cuff is going to give her arm a big hug
Tell the child that the blood pressure cuff is asleep and cannot wake up
Give the blood pressure cuff a name and refer to it by this name during the assessment
Tell the child by using the blood pressure cuff we can see how strong their muscles are
A 16 year old has just been admitted to the hospital for overnight observation after being in an automobile accident. What is the best approach for the nurse to use to communicate with this patient?
Use periods of silence to communicate respect for the patient
Be totally honest with the patient even if the information is unpleasant
Tell the patient that everything that is discussed will be kept totally confidential
Use slang language when possible to help the patient open up
A 75 year old woman is at the office for her preoperative interview. The nurse is aware that the interview may take longer than interviews with younger people. What is the reason for this?
An older adult has a longer story to tell
An older adult is usually lonely and likes to have someone with whom to talk
Older adults lose much of their mental abilities and require longer time to complete an interview
As a person ages they are unable to hear thus the interviewer usually needs to repeat much of what is said
The nurse is interviewing a patient who has a hearing impairment and came in because of a cold. What techniques would be most beneficial in communicating with this patient?
Determine the communication method the patient prefers
Avoid using facial and hand gestures because most hearing impaired people find them degrading
Request a sign language interpreter before meeting with the patient to help facilitate the communication
Speak loudly and with exaggerated facial movement when talking to the patient because doing so will help him lip read
During a prenatal check a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy which ended in miscarriage. Which is the best response by the nurse?
I'm so sorry for making you cry
I can see that you are sad remembering this it is all right to cry
Why don't I step out for a minute until you're feeling better
I can see that you feel sad about this why don't we talk about something else
The nurse is performing a health interview on a patient who has a language barrier and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation.
Do you take any medicine
Are you in any discomfort
Do you have nausea or vomiting
You have been following your doctor's orders haven't you
A patient arrives at the clinic for their annual Wellness physical. The patient is not experiencing any acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview?
How is your family
How is your job
Tell me about your hypertension
How has your health been since your last visit
The nurse says to a patient, "I know it may be hard but you should do what your doctor ordered because the doctor is the expert in this field." which statement is correct about the nurse's comment?
It is inappropriate because it shows the nurse's bias
It is appropriate because members of the health care team are experts in their area of patient care
This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation
Using authority statements when dealing with patients especially when they are undecided about an issue is necessary at times
A patient does not speak English well and the nurse needs to choose an interpreter. Which would be the most appropriate choice?
Trained interpreter
Male family member
Female family member
Volunteer college student from the Foreign Language Studies department
During a follow up visit the nurse discovers that a patient has not been taking their insulin on a regular basis. The nurse asks, " Why haven't you taken your insulin?" Which statement is an appropriate evaluation of this situation?
This question may place the patient on the defensive
This question is an effective way to search for information
Discussing their behavior with their spouse would have been better
A direct question is the best way to discover the reasons for the patient's behavior
The nurse is nearing the end of an interview. Which statement is appropriate at this time?
Did we forget something
Is there anything else you would like to mention
I need to go on to the next patient I'll be back
While I'm here let's talk about your upcoming surgery
What data should the nurse collect during the interview portion of a health assessment?
Physical
Historical
Objective
Subjective
During an interview the nurse would expect that most of the interview will take place at what distance?
Intimate zone
personal distance
Social distance
Public distance
A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview the patient makes an overtly sexual comment. Which is the best response by the nurse?
Stop that immediately
Oh you are too funny let's keep going with the interview
Do you really think I would be interested
It makes me uncomfortable when you talk that way please stop
The nurse is conducting an interview. Which of these statements is true regarding open-ended questions?
Elicit hard facts
Allow for self expression
Build and enhance rapport
Call for short one to two word answers
Are used when narrative information is needed
The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation.
Collect the patient's data in a direct face to face manner
Enter all the data as the patient states them
Ask the patient to wait as the nurse enters the data
Type the data into the computer after the narrative is fully explored
Allow the patient to see the monitor during typing
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 the nurse
To provide a form for obtaining the patients biographic information
To document the normal and abnormal findings of a physical assessment
To provide a database of subjective and objective data about the patient
When the nurse is evaluating the reliability of a patient's response which of these statements would be correct?
Patient has a history of drug abuse and therefore is not reliable
Patient provided consistent information and therefore is reliable
Patient smiled throughout interview and therefore is assumed reliable
Patient will not answer questions concerning stress and therefore is not reliable
A 59 year old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care?
JM is a 59 year old man seeking treatment for ulcerative colitis
JM came into the clinic reporting black stools for the past 24 hours
JM is a 59 year old man who states that he has ulcerative colitis and wants it checked out
JM is a 59 year old man who states that he has been having black stool for the past 24 hours
A patient reports having bad abdominal pain for the past week. What would be the nurse's best response?
Can you point to where it hurts
What have you had to eat in the last 24 hours
Have you ever had any surgeries on your abdomen
We'll talk more about that later in the interview
A 29 year old woman tells the nurse that she has excruciating pain in her back. Which response by the nurse would be appropriate?
How does your family react to your pain
The pain must be terrible. You probably pinched a nerve
I have back pain myself and it could be excruciating
How would you say the pain affects your ability to do your daily activities
In recording the childhood illness of a patient who denies having had any which note by the nurse would be most accurate?
Patient denies usual childhood illness
Patient states he was a very healthy child
Patient states his sister had measles but he didn't
I put my glance on and left patient denies measles mumps rubella chicken pox pertussis and strep throat
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?
P-6, B-4, Ab-2
Grav 6, Term 4, Ab-2, living 4
Patient has had four living babies
Patient has been pregnant six times
a patient reports being allergic to penicillin What is the best response by the nurse?.
Are you allergic to any other drugs
How often have you received penicillin
Describe what happens to you take penicillin
I'll write your allergy on your chart so you won't receive any penicillin
The nurse is taking a family history. Which specific disease or problem would be included in the assessment?
Emphysema
head trauma
Mental illness
Fractured bones
What does the review of systems provide the nurse?
Physical findings related to each system
Information regarding health promotion practices
An opportunity to teach the patient medical terms
Information necessary for the nurse to diagnose the patient's medical problem
What subjective information obtained by the nurse regarding a patient's skin should the nurse record in the patient's health history?
Skin appears dry
No lesions are obvious
Patient denies any color change
Lesion is noted on the lateral aspect of the right arm
The nurse is obtaining a history from a 30 year old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
Do you perform testicular self examinations
Have you ever noticed any pain in your testicles
Have you had any problems with passing urine
Do you have any history of sexually transmitted infections
Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
I broke my right leg in a car accident two weeks ago
The pain is decreasing but I still need to take acetaminophen
I checked 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
In response to a question about stress a 39 year old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate?
This has been a difficult year for you
I don't know how anyone can handle that much stress in one year
What did you do to cope with the loss of both your husband and mother
This is a lot of stress now let's go on to the next section of your history
In response to a question regarding the use of alcohol a patient asked the nurse why the nurse needs to know. What is the reason for needing this information?
This information is necessary to determine the patient's reliability
Alcohol can interact with all medications and can make some diseases worse
The nurse needs to be able to teach the patient about the dangers of alcohol use
This information is not necessary unless a drinking problem is obvious
The mother of a 16 month old toddler tells the nurse that her daughter has an earache. What would be an appropriate response by the nurse?
Maybe she is chest teething
I will check her ear for an ear infection
Are you sure she is really having pain
Describe what she is doing to indicate that she is having pain
During an assessment of a patient's family history the nurse constructs a genogram. Which statement best describes a genogram?
List of diseases present in a person's near relatives
graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members
Drawing that depicts the patient's family members up to five generations back
Description of the health of a person's children and grandchildren
A five year old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
Child's birth weight
Age at which he crawled
Whether the child has had the measles
Child's reaction to previous hospitalizations
As part of the health history of a six year old boy at a clinic for a sports physical examination the nurse reviews his immunization record and notes that his last measles mumps rubella vaccination was at 15 months of age. what should the nurse recommend?
No further MMR immunizations are needed
MMR vaccination needs to be repeated at four to six years of age
MMR immunization needs to be repeated every four years until age 21
A recommendation cannot be made until the position is consulted
In obtaining a review of systems on a healthy 7 year old girl what should the health care provider be sure to include?
Last glaucoma examination
Frequency of breast self examinations
Date of her last electrocardiogram
Limitations related to her involvement in sports activities
When the nurse asked for a description of who lives with a child the method of discipline and the support system of the child what part of the assessment is being performed?
Family history
Review of systems
Functional assessment
Reason for seeking care
The nurse is performing a functional assessment on an 82 year old patient who recently had a stroke. Which of these 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
The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
The functional assessment assesses how the individual is coping with life at home
It determines how children are meeting developmental milestones
The functional assessment can identify any problems with memory the individual may be experiencing
It helps determine how a person is managing day-to-day activities
The nurse is asking a patient for his reason for seeking care and ask about the signs and symptoms he is experiencing. Which of these is an example of a symptom?
chest pain
Clammy skin
Serum Potassium level at 4.2 mEq/L
Body temperature of 100 degrees Fahrenheit
A patient is describing his symptoms to the nurse. Which of these statements reflect a description of the setting of his symptoms?
It is a sharp burning pain in my stomach
I also have the sweats and nausea when I feel this pain
I think this pain is telling me that something bad is wrong with me
This pain happens every time I sit down to use the computer
During an assessment the nurse uses the CAGE test. The patient answers 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 thoroughly examined for possible alcohol withdrawal symptoms
The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment
The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the community portion of the FICA questions.
Do you believe in God
Are you a part of any religious or spiritual congregation
Do you consider yourself to be a religious or spiritual person
How does your religious faith influence the way you think about your health
The nurse is preparing to complete a health assessment on a 16 year old whose parents have brought her to the clinic. Which instruction would be appropriate for the parent before the interview begins?
It would help to interview the three of you together
While I interview your daughter will you step out to the waiting room and complete these family health history questionnaires
Please stay during the interview you can answer for her if she does not know the answer
While I interview your daughter will you please stay in the room and complete these family health history questionnaires
The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history?
Why did you come to the United States
When did you come to the United States and from what country
What made you leave your native country
Are you planning to return to your home
The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed?
Where is the headache pain
Did you have these headaches as a child
On a scale of one to 10 how bad is the pain
How often do the headaches occur
What makes the headaches feel better
The nurse is conducting a developmental history on a 5 year old child. Which questions are appropriate to ask the parents for this part of the assessment?
Can he till time
Does he have any food allergies
Does he take a children's vitamin
How much junk food does your child eat
How many teeth has he lost and when did he lose them
During an examination the nurse assesses mental status by which activity?
Examining the patient's electroencephalogram
Observing the patient as he or she performs an intelligence quotient test
Observing the patient and inferring mental functioning
Examining the patient's response to a specific set of questions
The nurse is assessing the mental status of a child. which statement about children and mental status is true?
All aspects of mental status in children are interdependent
Children are labile and unstable until the age of 2 years old
A child's mental status is impossible to assess until the child develops the ability to concentrate
Children's mental status is largely a function of their parents level of functioning until the age of seven years old
The nurse is assessing a 75 year old man. What should the nurse expect when performing the mental status portion of the assessment?
Will have no decrease in any of his abilities including response time
Will have difficulty on tests of remote memory because this ability typically decreases with age
May take a little longer to respond but his general knowledge and abilities should have not declined
Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge
When assessing aging adults what is one of the first things the nurse should assess before making judgments about the aging person's mental status?
Presence of phobias
General intelligence
Sensory perceptive abilities
Presence of irrational thinking patterns
The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?
The patients family is the best resource for information about the patients coping skills
Gathering mental status information during the health history interview is usually sufficient
Integrating the mental status examination into the health history interview takes an enormous amount of extra time
To get a good idea of the patient's level of functioning performing a complete mental status examination is usually necessary
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action?
Perform a complete mental status examination
Refer him to a psychometrician
Plan to integrate the mental status examination into the history and physical examination
Reassure his wife that memory loss after a physical shock is normal and will soon subside
The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status during the interview?
I sleep like a baby
I have no health problems
I never did too good in school
I am not currently taking any medication
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. How should the nurse proceed?
Defer the rest of the mental status examination
Skip the language portion of the examination and proceed on to assessing mood and effect
Conduct an in depth speech evaluation and defer the mental status examination to another time
Proceed with the examination and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression
A 19 year old woman comes to the clinic at insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. Which is an appropriate conclusion for the nurse to draw?
She probably does not have any problems
She is only trying to shock people and that her dress should be ignored
She has maniac syndrome because of her abnormal dress and grooming
More information should be gathered to decide whether her dress is appropriate
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical surgical unit and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during the patients test of cognitive function?
May display some disruption in thought content
Will state I am so relieved to be out of intensive care
Will be oriented to place and person but the patient may not be certain of the date
May show evidence of some clouding of his level of consciousness
During a mental status examination the nurse wants to assess a patient's affect. Which question would the nurse ask?
How do you feel today
Would you please repeat the following words
Have these medications had any effect on your pain
Has this pain affected your ability to get dressed by yourself
The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this?
Administer the FACT test
Ask him to describe his first job
Give him the four unrelated words test
Ask him to describe what television show he was watching before coming to the clinic
The patient is at the clinic for a mental status assessment. Which describes the expecting findings on the four unrelated words test?
Invents four unrelated words within five minutes
Invents four unrelated words within 30 seconds
Recalls four unrelated words after a 30 minute delay
Recalls four unrelated words after a 60 minute delay
During a mental status assessment which questioned by the nurse would best assess a person's judgment?
Do you feel that you are being watched followed or controlled
Tell me what you plan to do once you are discharged from the hospital
What does the statement People in glass houses shouldn't throw stones mean to you
What would you do if you found a stamped addressed envelope lying on the sidewalk
Which of these individuals will the nurse consider at high risk for a suicide attempt?
Man who jokes about death
Woman who during a past episode of major depression attempted suicide
Adolescent who just broke up with her boyfriend and states that she would like to kill herself
Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun
The nurse is assessing orientation in a 79 year old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
I know my name is John I couldn't tell you where I am I think it's two 1010 though
I know my name is John but to tell you the truth I get kind of confused about the date
I know my name is John I guess I'm at the hospital in Spokane I don't know the date
I know my name is John I am at the hospital in Spokane I couldn't tell you what the date is but I know that it is February of a new year 2010
The nurse is performing the Denver II screening test on a 12 month old infant during a routine well child visit. What should the nurse tell the infant's parents about the Denver II screening test?
Test three areas of development; cognitive physical and psychological
Will indicate whether the child has a speech disorder so that treatment can begin
Is a screening instrument designed to detect children who are slow in development
Is a test to determine intellectual ability and may indicate whether problems will develop later in school
A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her by calling her name but the patient remains drowsy during the conversation. What is the best description of this patient's level of consciousness?
Lethargic
Obtunded
Stuporous
Semi coma
A patient has had a cerebrovascular accident. He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train". What is the best description of this patient's problem?
Echolalia
Global aphasia
Broca's aphasia
Wernicke's Aphasia
A patient repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." How should the nurse record this on his chart?
Blocking
Neologism
Circumlocution
Circumstantiality
During an examination the nurse notes that a patient is exhibiting flights of ideas. Which statement by the patient is an example of flight of ideas?
My stomach hurts. hurts, spurts, burts
Kiss wood reading ducks onto maybe
I wash my hands wash them wash them I usually go to the sink and wash my hands
Take this pill the pill is red I see red red velvet is soft soft as a baby's bottom
The patient describes feeling an unreasonable irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient's condition?
A snake phobia
A hypochondriac
An obsession with snakes
A delusion that snakes are harmful stemming from an early traumatic incident involving snakes
During a recent interview a patient diagnosed with schizophrenia shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying and then laughs loudly at the content. What is the best description of this behavior?
Confusion
Ambivalence
Depersonalization
Inappropriate effect
During change of shift report the nurse hears that a patient is experiencing hallucinations. What is an example of a hallucination?
Man hears his dead wife is talking to him
Woman who believes she is the President of the United States
Child sees a man standing in his closet. when the lights are turned on it is only a dry cleaning bag
Man believes that the dog has curled up on the bed but when he gets closer he sees that it is a blanket
A 20 year old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient what should the nurse assess first?
Affect and mood
Memory and affect
Cognitive abilities
Level of consciousness
A 26 year old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow up assessment. The nurse will want to ask her which of these questions?
How are things going with the trial
How are things going with your job
Tell me about your recent engagement
Are you having any disturbing dreams
The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
Mental status assessment diagnosis specific psychiatric disorder
Mental disorders occur in response to everyday life stressors
Mental status functioning is inferred through the assessment of an individual's behaviors
Mental status can be directly assessed similar to other systems of the body
A 23 year old patient in the clinic appears anxious. Her speech is rapid and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation?
How do you usually feel? Is this normal behavior for you?
I am going to say 4 words. In a few minutes I will ask you to recall them.
Describe the meaning of the phrase looking through rose colored glasses
Pick up the pencil in your left hand move it to your right hand and place it on the table
The nurse is planning health teaching for a 65 year old woman who has had a stroke and has aphasia. Which of these questions is most important to use when assessing the mental status of this patient.
Please count backwards from 100 by 7
I will name three items and ask you to repeat them in a few minutes
Please point to articles in the room and parts of the body as I name them
What would you do if you found a stamped addressed envelope on the sidewalk
A 30 year old patient is describing feelings of hopelessness and depression. She has attempted self mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. These statements or questions is the nurse best response in this situation?
Do you have a weapon
How do other people treat you
Are you feeling so hopeless that you feel like hurting yourself now
People often feel hopeless but the feelings resolve within a few weeks
Is providing instructions to newly hired graduates for the mini mental state examination. Best describes this examination?
Scores below 30 indicate cognitive impairment
The MMSE is a good tool to evaluate mood and thought process
Examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness
Useful tool for an initial evaluation of mental status. Tools are needed to evaluate cognitive changes overtime.
The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech but is mostly absent or is reduced to a fused stereotypical words or sounds. This finding reflects which type of aphasia?
Global
Broca
dysphonic
Wernickes
The patient repeats, "I feel hot. hot, cot, rot, tot, got. i'm a spot." What term should the nurse use to document this?
Blocking
Clanging
Echolalia
Neologism
During an interview the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. An example of what behavior?
Social phobia
Compulsive disorder
Generalized anxiety disorder
Post Traumatic Stress Disorder
The nurse is administering a mini cog test to an older adult woman. Clock showing the time of 10:45 the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding?
Amnesia
Delirium
Cognitive impairment
attention deficit disorder
During morning rounds the nurse asks a patient, " How are you today?" The patient responds, " You today, you today, you today!" and mumbles the words. This is an example of which speech pattern?
Echolalia
Clanging
Word salad
Perseveration
The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium?
Person experiences agnosia
Person demonstrates apraxia
Develops over a short period
Person exhibits memory impairment or deficits
Occurs as a result of a medical condition such as systemic infection
A patient has come to the clinic to seek help with a substance abuse problem. The patient admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining the patient?
Dilated pupils pacing and psychometer agitation
Dilated pupils unsteady gait and aggressiveness
Pupil constriction lethargy apathy and dysphoria
Constricted pupils euphoria and decreased temperature
The nurse is assessing a patient who has been admitted for cirrhosis of the liver secondary to chronic alcohol use. Estimate finding what the nurse expect?
Hypertension
Ventricular fibrillation
Bradycardia
Mitral valve prolapse
The nurse is conducting a class on alcohol and the effects of alcohol on the body. What information about the amount of alcohol is associated with an increase of breast cancer, would the nurse include in the class?
less than 10-15 grams of alcohol a day
more than 20g of alcohol a day
more than or equal to 8 drinks a week
More than or equal to 15 drinks a week
A session on substance abuse the nurse is reviewing statistics with the class. Which illicit substance would the nurse report as most commonly used
Heroin
Marijuana
Crack cocaine
Hallucinogen
A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asked the nurse, " How many drinks a day is safe for my baby?" What is the best response by the nurse?
Limit your drinking to once or twice a week
It's okay to have up to two glasses of wine a day
As long as you avoid getting drunk you should be safe
No amount of alcohol has been determined to be safe during pregnancy
During an assessment the nurse asks a female patient, " How many alcoholic drinks do you have a week?" Which answer by the patient would indicate at risk of drinking?
I may have one or two drinks a week
Drinks a week
Last or two of wine every now and then
I have eight to 10 drinks a week but I never get drunk
The nurse is asking an adolescent about illicit drug abuse. The adolescent answers, " Yes I've used marijuana at parties with my friends." What is the next question the nurse should ask?
Who are these friends
Is this a regular habit
Do your parents know about this
When was the last time you used marijuana
The nurse has completed an assessment on an older adult patient who came into the clinic for a leg injury. As a result of the assessment the nurse has determined that the patient has at risk alcohol use. Which action by the nurse is most appropriate at this time?
The results of the assessment and notify the physician on call
State, " You are drinking more than is medically safe. Recommend that you quit drinking and I'm willing to help you."
State, " It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter."
Give the patient information about a local rehabilitation clinic
A patient is brought to the emergency department. He is restless has dilated pupils is sweating has a runny nose and tearing eyes and reports muscle and joint pains. His girlfriend thought he had influenza but she became concerned when his temperature went up to 102.9. That he has been a heavy drug user but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?
Alcohol
Heroin
Cocaine
Sedatives
The nurse is reviewing aspects of substance abuse in preparation for a seminar. These statements illustrates the concept of tolerance to an illicit substance?
A physiological dependence on a substance
A person requires an increased amount of the substance to produce the same effect
A person requires daily use of the substance to function and is unable to stop using it
A person experiences a syndrome of physiologic symptoms if the substance is not used
The nurse is admitting a patient with an alcohol use disorder to a treatment center. Which street tools should the nurse use to assess for symptoms of alcohol withdrawal?
TWEAK
AUDIT
SMAST-G
CIWA-Ar
The nurse is conducting an interview with the patient. Which statement made by the patient indicates an alcohol use disorder?
I crave alcohol but have successfully cut down on my alcohol consumption
I've been late to work a few times so now I limit myself to two drinks a day and stick to it
More than I intend but I still make it into work on time
I have a strong urge to drink and I've tried to stop drinking several times but it doesn't last long
When reviewing the use of alcohol by older adults the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase availability of alcohol in the blood for longer periods in the older adult?
Increased muscle mass
Decreased blood pressure
Increased cardiac output
Decreased liver metabolism
Decreased kidney functioning
A patient with a known history of heavy alcohol use has been admitted to the ICU after being found unconscious outside a bar. Which of these symptoms may occur during this time?
Bradycardia
Coarse tremor of the hands
Transient hallucinations
Somnolence
Sweating
A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop "cold Turkey". He asked the nurse, " What symptoms can I expect if I do this?" Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal?
Headaches
Hunger
Sleepiness
Restlessness
Nervousness
As a mandatory reporter of older adult abuse which must be present before a nurse would notify the authorities?
Statements from victim
Statements from witnesses
Proof of abuse or neglect
Suspicion of older adult abuse or neglect
During a home visit the nurse notices that an older adult woman is caring for her bedridden husband. The woman states that this is her duty she does the best she can and her children come to help when they are in town. Her husband is unable to care for himself and she appears thin weak and exhausted. The nurse notices that several of his prescription medication bottles are empty. What term best describes this situation?
Physical abuse
Financial exploitation
Psychological abuse
Neglect
The nurse is caring for a 17 year old female patient. In which situation would the nurse screen the patient for intimate partner violence?
When intimate partner violence is suspected
When a history of abuse in the family is known
As a routine part of each health care encounter
As part of the exam for a female with an unexplained injury
Which term refers to a wound produced by the tearing or splitting of body tissue usually from blunt impact over a Bony surface?
Hematoma
Abrasion
Contusion
Laceration
During an examination the nurse notices a pattern injury on a patient's back. What would cause such an injury?
Blunt force
Friction abrasion
Stabbing from a kitchen knife
Whipping from an extension cord
What would the nurse include when documenting IPV and older adult abuse?
Photographic documentation of the injuries
Summary of the abused patient's statement
General description of injuries in the Progress notes
Verbatim documentation of every statement made by the victim
A female patient has denied any abuse when answering the questions on an abuse assessment screening tool but what finding by the nurse during the interview process is associated with IPV?
Asthma
Confusion
Depression
Frequent colds
The nurse suspects abuse when a 10 year old child is taken to the urgent care center for a leg injury. Which is the best way for the nurse to document the findings in the patient's chart?
Rely on photographs of the injury
Document what the child's caregiver tells the nurse
Record what the nurse observes during the conversation
Use the words the child has said to describe how the injury occurred
The nurse is examining a three year old child who was brought to the emergency department after a fall. Which bruise if found would be of most concern?
Bruises on the knee
Bruises on the elbow
Bruises on the abdomen
Bruises on both of the shins
The nurse is caring for an eight year old child who has several bruises of varying colors the size of a hand on the buttocks. What action would the nurse take next?
Notified the child's caregivers of the findings
That the bruises appear to be caused by spanking
When the child is alone ask How did you get these sore areas on your buttocks
Inform the child you can tell me who did this to you and we will not allow them to see or hurt you again
The nurse is caring for several patients on a pediatric unit. which patient the nurse be most concerned about possible abuse?
A four month old with bruises on the arm
A two year old with bruises on the knee
An 8 year old with a broken right arm
A 15 year old football player with a broken leg
The nurse is caring for several patients. Which patient is at highest risk for intimate partner violence?
An Asian female who speaks no English
A female multiracial illegal immigrant
A non Hispanic white female living in poverty
A female American indian living above the poverty line
The nurse assesses an older woman and suspects physical abuse. Which questions are appropriate for screening for abuse?
Has anyone made you afraid touched you in ways that you did not want or hurt you physically
Are you being abused
Have you relied on people for any of the: Bathing, dressing, shopping, banking, or meals
Have you been upset because someone talked to you in a way that made you feel shamed or threatened
Has anyone tried to force you to sign papers or to use your money against your will
The nurse plans to interview a patient using the HITS tool. The nurse would ask how often the patient's partner does which things?
Physically hurt you
Insult or talk down to you
Threaten you with harm
Scream or curse at you
Force you to sign papers against your will
