RN NURSING FINAL Exam Test Bank Questions & with Answers (From Real Exam), Rated 100%-What data should the nurse collect during the interview portion of a ... [Show More] health assessment?
a. Physical
b. Historical
c. Objective
d. Subjective - d. Subjective
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?
a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
b. J.M. came into the clinic complaining of having black stools for the past 24 hours.
c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked.
d. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours. - d. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours.
The nurse is nearing the end of an interview. Which statement is appropriate at this time?
a. "Did we forget something?"
b. "Is there anything else you would like to mention?"
c. "I need to go on to the next patient. I'll be back."
d. "While I'm here, let's talk about your upcoming surgery." - b. "Is there anything else you would like to mention?"
When the nurse asks 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?
a. Family history
b. Review of systems
c. Functional assessment
d. Reason for seeking care - c. Functional assessment
The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?
a. Belief in and the worship of God or gods
b. Being closely tied to one's ethnic background
c. Attendance at a specific church or place of worship
d. A connection with something larger than oneself and belief in transcendence - d. A connection with something larger than oneself and belief in transcendence
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
a. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate.
b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.
d. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded. - c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.
A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. Why is it important for the nurse to consider the basics of the patient's culture during the patient's health assessment?
a. Identify the cause of his illness.
b. Make accurate disease diagnoses.
c. The U.S. is becoming increasingly diverse.
d. Provide culturally relevant health care. - d. Provide culturally relevant health care.
The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individual's behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds). - c. Mental status functioning is inferred through the assessment of an individual's behaviors.
The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment?
a. Will have no decrease in any of his abilities, including response time.
b. Will have difficulty on tests of remote memory because this ability typically decreases with age.
c. May take a little longer to respond, but his general knowledge and abilities should not have declined.
d. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge. - c. May take a little longer to respond, but his general knowledge and abilities should not have declined.
A nurse is helping at a health fair at a local mall. What should the nurse keep in mind when taking blood pressures on a variety of people?
a. After menopause, blood pressure readings in women are usually lower than those taken in men.
b. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight.
d. A teenager's blood pressure reading will be lower than that of an adult. - b. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
Which technique is correct when the nurse is assessing the radial pulse of a patient?
a. Palpate for 1 minute, if the rhythm is irregular.
b. Palpate for 15 seconds and multiply by 4, if the rhythm is regular.
c. Palpate for 2 full minutes to detect any variation in amplitude.
d. Palpate for 10 seconds and multiply by 6, if the rhythm is regular and the patient has no history of cardiac abnormalities. - a. Palpate for 1 minute, if the rhythm is irregular.
A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?
a. Allow 5 minutes for him to relax and rest before checking his vital signs.
b. Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise.
c. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences.
d. Check his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time.
Feedback - a. Allow 5 minutes for him to relax and rest before checking his vital signs.
The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?
a. Acromegaly
b. Marfan syndrome
c. Hypopituitary dwarfism
d. Achondroplastic dwarfism - c. Hypopituitary dwarfism
When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. What action should the nurse take in this situation?
a. Ask someone who knows the patient well to help interpret this discrepancy.
b. Focus on the patient's verbal message, and try to ignore the nonverbal behaviors.
c. Try to integrate the verbal and nonverbal messages and then interpret them as an average.
d. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings. - d. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings.
The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
a. All aspects of mental status in children are interdependent.
b. Children are highly labile and unstable until the age of 2 years.
c. A child's mental status is impossible to assess until the child develops the ability to concentrate.
d. Children's mental status is largely a function of their parents' level of functioning until the age of 7 years. - a. All aspects of mental status in children are interdependent.
When caring for children with a different cultural perspective, what should the nurse recognize may pose a challenge?
a. Children have spiritual needs that are influenced by their stages of development.
b. Children have spiritual needs that are direct reflections of what is occurring in their homes.
c. Religious beliefs rarely affect the parents' perceptions of the illness.
d. Parents are often the decision makers, and they have no knowledge of their children's spiritual needs. - a. Children have spiritual needs that are influenced by their stages of development.
A 30-year-old female 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. Which of these statements or questions is the nurse's best response in this situation?
a. "Do you have a weapon?"
b. "How do other people treat you?"
c. "Are you feeling so hopeless that you feel like hurting yourself now?"
d. "People often feel hopeless, but the feelings resolve within a few weeks." - c. "Are you feeling so hopeless that you feel like hurting yourself now?" [Show Less]
