Question: NUR2092 Section 03 Health Assessment Exam 1.
NUR2092 Section 03 Health Assessment – Online – Winte
• Question 1 Which statement defines dementia?
gradual progressive decrease in cognition which is not reversible
confusional change which resolves with treatment
aware of one’s existence or feelings
unwanted persistent thoughts or impulses
• Question 2:
an interview, the nurse notes that the patient gets up several times to wash
her hands even though they are not dirty. This is an example of:
generalized anxiety disorder.
posttraumatic stress disorder
of the following is an example of a first-level priority problem?
patient with postoperative pain
newly diagnosed diabetic who needs diabetic teaching
An individual with a small laceration
on the sole of the foot
individual with shortness of breath and respiratory distress
patient drifts off to sleep when she is not being stimulated. The nurse can
arouse her easily when calling her name, but she remains drowsy during the
conversation. The best description of this patient’s level of consciousness would
5 A 45-year-old woman is
brought to the emergency department with a head injury after her car hit a
tree. A few months after recovering from her injuries, she is unable to learn
new information or recall previously learned information. This is an example
6 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, the nurse knows that which statement is most
accurate? The woman:
is excited about her pregnancy but nervous about labor.
exhibiting verbal and nonverbal behavior that does not match.
excited about her pregnancy but her husband is not and this is upsetting to
excited about her pregnancy but believes the nurse will respond negatively to
her if she states this.
completing an initial assessment on a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58. This type of data would be:
of the following is the best definition of spirituality?
personal search to discover a supreme being
organized system of beliefs concerning the cause, nature, and purpose of the
belief that each person exists forever in some form, such as a belief in
reincarnation or the afterlife
which arises out of each person’s unique life experience and his or her
personal effort to find purpose in life
of the following examples would be a hallucination?
man believes that his dead wife is talking to him.
woman hears the doorbell ring and goes to answer it, but no one is there.
child sees a man standing in his closet. When the lights are turned on it is
only a dry cleaning bag.
believes that the dog has curled up on the bed, but when he gets closer he sees
that it is a blanket.
Symptoms, such as pain, are often influenced by a person’s cultural
heritage. Which of the following is a true statement in regard to pain?
Nurses’ attitudes toward their patients’ pain are unrelated to their own
experiences with pain.
ethnic background of a patient is important in a nurse’s assessment of that
nurse’s area of clinical practice is most likely to determine his or her assessment
of a patient’s pain.
nurse’s years of clinical experience and current position are a strong
indicator of his or her response to patient pain.
patient tells the nurse that he is allergic to penicillin. What would be the
nurse’s best response to this information?
“Are you allergic to any other drugs?”
often have you received penicillin?”
write your allergy on your chart so you won’t receive any.”
“Please describe what happens to you when you take penicillin.”
• Question 12
data would not be included in a client’s health history?
Family Medical History
data would a nurse document under the category of family health history?
Allergies to Medications
ClientÕs name and date of birth
• Question 14
“A client with cancer says, I feel like I am getting weaker every
day. I wonder if the chemotherapy is working. The nurse responds, Isn’t it
beautiful outside today? This interaction is an example of what specific type
of communication barrier?”
Changing the subject or topic
Falsely reassuring statement
scenario described below best illustrates a screening type of health
client visits an obstetric clinic for the first time, and the nurse conducts a
detailed history and physical examination.
hospital sponsors a health fair at a local mall and provides cholesterol and
blood pressure checks to mall patrons.
nurse in the triage area of an urgent care center checks the vital signs of a
client who is complaining of leg pain.
client make an appointment 1 month after today’s office visit for a follow-up
test of fasting blood glucose level.
largest and fasting growing population in the United States is:
following statement could be found at which phase of the interview? “Mr. S., 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.”
During the summary
Closing the interview
the body of the interview
Opening/introducing the interview
Culture has four basic characteristics. Which statement correctly
reflects one of these characteristics?
Cultures are static and unchanging despite changes around them.
Cultures are never specific, which makes them
hard to identify.
Culture is most clearly reflected in a person’s language and behavior.
Culture adapts to specific environmental factors and available natural
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?”
did you come to the United States, and from what country?”
made you leave your native country?”
you planning to return to your home?”
of the following culture-bound syndromes is more common among North
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, (S)Ab-2
6, Term 4, (S)Ab 2, Living 4
Patient has had four living babies.
Patient has been pregnant six times.
• Question 22
20-year-old construction worker has been brought into the emergency department
with heat stroke. He has delirium as a result of the fluid and electrolyte
imbalance. The nurse will assess his:
affect and mood.
thought processes and memory.
of consciousness and cognitive abilities.
interview, the nurse may find it necessary to take notes to aid his or her
memory later. Which of the following statements is true regarding
Taking notes may impede the nurse’s observation of the patient’s
notes allows the patient to continue at his or her own pace as the nurse
records what is said.
notes allows the nurse to shift attention away from the patient, resulting in
increased comfort level.
notes allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort.
90-year-old patient tells the nurse that he can’t remember the names of the
drugs he is taking or what they are for. An appropriate response would be:
“Can you tell me what they look like?”
worry about it. You are only taking two.”
long have you been taking each of the pills?”
you have your family bring in your medications?”
nurse is assessing mental status in children. Which of the following statements
All aspects of mental status in children are interrelated.
Children are highly labile and unstable until the age of 2 years.
Children’s mental status is largely a function of their parents’ level
of functioning until the age of 7 years.
Children’s mental status is impossible to assess until the child
develops the ability to concentrate.
intervention by the nurse first helps to establish a trusting nurse-patient
provoke emotional responses from the patient
listening to the patient while performing care activities
performing care interventions quickly and efficiently
greeting the patient by name whenever entering the patient’s room
individuals embrace the hot/cold theory of health illness. Which of the
following best describes the basic tenets of this theory?
The causation of illness is based on supernatural forces that influence
the humors of the body.
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
treatment of disease consists of adding or subtracting cold, heat, dryness, or
wetness to restore the balance of the humors of the body.
female patient does not speak English well, and the nurse needs to choose an
interpreter. Which of the following would be the most appropriate choice?
female family member
volunteer college student from the foreign language studies department.
statement is correct regarding the development of one’s culture?
Culture is genetically determined on the basis of racial background.
Culture is learned through language acquisition and socialization.
Culture is a nonspecific phenomenon and is adaptive but unnecessary.
Culture is biologically determined on the basis of physical
of the following statements is true regarding the assessment of mental
Mental status assessment diagnoses specific psychiatric disorders.
disorders occur in response to everyday life stressors.
status functioning is inferred through assessment of an individual’s behaviors.
status can be assessed directly, just like other systems of the body (e.g.,
cardiac and breath sounds).
data do nurses document under the category of past health history?
Allergies to Medications
and date of birth
42-year-old Asian patient is being seen at the clinic for an initial
examination. The nurse knows that it is important to include cultural
information in his health assessment to:
the cause of his illness
accurate disease diagnoses.
provide cultural health rights for the individual
provide culturally sensitive and appropriate care.
of following is included in documenting a history source?
Reliability of informant
Cognition and literacy level of the
“Appearance, dress and hygiene of the client”
Documented relationship of support systems of the client
of the following responses might the nurse expect during a functional
assessment of a patient whose leg is in a cast?
Answers: “I broke my right leg in a car accident 2
pain is getting less, but I still need to take Tylenol.”
check the color of my toes every evening just like I was taught.”
able to transfer myself from the wheelchair to the bed without help.”
of the following is an example of a folk healer?
response to a question regarding use of alcohol, a patient asks the nurse why
the nurse needs to know. What is the reason for needing this information?
This is necessary to determine the patient’s reliability.
Alcohol can interact with all medications and make some diseases worse.
nurse needs to be able to teach the patient about the dangers of alcohol use.
not really necessary to have this information unless there is an obvious
of the following illustrates an appropriate category in a cultural
38: NUR2092 Section 03 Health Assessment Exam 1
of the following is not a barrier to communication?
failure to listen
nurse that accuses the client of not following a diabetic diet when a serum
blood sugar of 200mg/dl is noted. This accusation upsets and angers the client.
This response is secondary to which form of communication barrier?
• Question 40: NUR2092 Section 03 Health Assessment Exam 1
nursing process is a sequential method of problem solving that includes which
assessment, treatment, evaluation, discharge, follow-up
admission, assessment, diagnosis, treatment, discharge planning
admission, diagnosis, treatment, evaluation, discharge planning
assessment, diagnosis, planning, implementation, evaluation
41: NUR2092 Section 03 Health Assessment Exam 1
of the following is an example of an “open-ended question”?
‘How have you been feeling today?’
you try home remedies for your symptoms?’
you drive yourself today?’
‘Did you call your doctor?’
42: NUR2092 Section 03 Health Assessment Exam 1
observing a patient’s verbal and nonverbal communication, the nurse notices a
discrepancy. Which statement is true regarding this situation?
Answers: The nurse should ask someone who knows
the patient well to help interpret this discrepancy.
nurse should focus on the patient’s verbal message and try to ignore the
nurse should try to integrate the verbal and nonverbal messages and then interpret
them as an “average.”
nurse should focus on the patient’s nonverbal behaviors because these are often
more reflective of a patient’s true feelings.
43: NUR2092 Section 03 Health Assessment Exam 1
“During an interview with your client, she is very talkative and is
sharing much information which is not pertinent to the reason for her admission
to the hospital. Which action by you would improve your data collection in this
Terminate the interview
client to stay on the subject
another nurse to complete the interview
objective data would a nurse obtain during a physical examination?
The client’s radial and apical pulse
client’s concern with their financial expenditures
complaints of numbness and tingling in their feet
client’s reason for being hospitalized
45: NUR2092 Section 03 Health Assessment Exam 1
nurse is assessing orientation in a 79-year-old patient. Which of the following
responses would lead the nurse to conclude that this patient is oriented?
“I know that my name is John. I couldn’t tell you where I am. I think it
is 2027, though.”
know that my name is John, but to tell you the truth, I get kind of confused
about the date.”
know that my name is John; I guess I’m at the hospital in Spokane. No, I don’t
know the date.”
know that my name is John. I am at the hospital in Spokane. I couldn’t tell you
what date it is, but I know that it is February of a new year—2007.”
“A client arrives at the emergency department with uncontrollable
crying and anxiety. The client’s spouse of 17 years has recently asked for a
divorce. The client is sitting in a chair, rocking back and forth. Which is the
best response for the nurse to make?”
can see how upset you are. Let’s sit in the office so that we can talk about
how you’re feeling.
You must stop crying so that we can
discuss your feelings about the divorce.
“Once you find a job, you’ll feel much better and more
Once you have a lawyer looking out for your interests, you will feel
47: NUR2092 Section 03 Health Assessment Exam 1
type of aphasia is the most common and severe form—spontaneous speech is absent
or it is reduced to a few stereotyped words or sounds?
48: NUR2092 Section 03 Health Assessment Exam 1
nurse is taking complete health histories on all the patients attending a
wellness workshop. On the history form, one of the written question asks, “You
don’t smoke, drink, or take drugs, do you?” This question is an example
talking too much.
biased or leading questions.
blunt language to deal with distasteful topics.
of the following statements best describes the purpose of a health
To provide an opportunity for interaction between patient and nurse
To provide a form for obtaining the patient’s
document the normal and abnormal findings of a physical assessment
provide a database of subjective information about the patient’s past and
the nurse is evaluating the reliability of a patient’s responses, which of the
following would be a correct statement?
The 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 would not answer questions concerning stress and therefore is not
of the following statements represents subjective data obtained from the patient
regarding his skin?
Skin appears dry.
No obvious lesions
Denies color change
noted lateral aspect right arm
Because the physical environment in which an interview takes place is an
important consideration for the success of an interview, the interviewer
the distance between the interviewer and the patient about 2 feet or closer.
provide a dim light that makes a room cozier and will help the patient
arrange seating across a desk or table to allow the patient some
assess affect, the nurse would know the definition as:
temporary expression of feeling or state of mind
aware of one’s own existence, feelings, and thoughts
durable, a prolonged display of feelings
awareness of an object in relation to the self
germ theory, which posits that microscopic organisms such as bacteria and
viruses are responsible for specific disease conditions, is a basic belief of
which theory of illness?
an assessment, the nurse uses the CAGE test. The patient answers “yes” to two
of the questions. What could this be indicating?
patient is an alcoholic.
patient is annoyed at the questions.
patient should be examined thoroughly for possible alcohol withdrawal symptoms.
nurse should suspect alcohol abuse and continue with a more thorough substance
an interview, a parent of a hospitalized child is sitting in an open position.
As the interviewer begins to discuss his son’s treatment, however, he suddenly
crosses his arms against his chest and crosses his legs. This would suggest
that the parent is:
Answers: just changing positions.
comfortable in this position.
and needs a break in the interview.
uncomfortable talking about his son’s treatment.
patient tells the nurse that he is very nervous, that he is nauseated, and that
he “feels hot.” This type of data would be:
health promotion model, the focus of the health professional includes:
changing the patient’s perceptions of disease
identification of biomedical model interventions
identifying negative health acts of the consumer
helping the consumer choose a healthier lifestyle
The public’s concept of health has
changed since the 1950s. Which of the following statements most accurately
describes this change?
Lifestyle, personal habits, exercise, and nutrition are essential to
Assessment of health is critical to identifying disease-causing
Accurate diagnosis and treatment by a physician are essential for all
individual is considered healthy when signs and symptoms of disease have been
the concept of prevention essential in describing health?
Disease can be prevented by treating the external environment.
majority of deaths among Americans under age 65 years are not preventable.
Prevention places emphasis on the link between health and personal
means to prevention is through treatment provided by primary health care
does the health assessment begin?
When the nurse initially meets the client
the client tells the nurse their name
the nurse asks the client the first health-related question
the client consents to have a health assessment
a clinic visit, 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?” The nurse’s most appropriate response
in this case would be:
“I’d quit. The doctor really knows what he is talking about.”
you like some information about the different ways a person can quit smoking?”
“Stopping your dependence on cigarettes can be very difficult. I
understand how you feel.”
are you confused? Didn’t the doctor give you the information about the smoking
cessation program we offer?”
example of objective information obtained during the physical assessment
Answers: patient’s history of allergies
use of medications at home
last menstrual period 1 month ago
scar present on the right lower forearm
recording the childhood illnesses of a patient who denies having had any, which
of the following notes by the nurse would be most accurate?
Patient denies usual childhood illnesses.
Patient states he was a “very healthy” child.
Patient states sister had measles, but he didn’t.
Patient denies measles, mumps, rubella, chickenpox, pertussis, or strep
statement is accurate regarding one’s ethnicity?
Ethnicity is dynamic and ever-changing.
Ethnicity is the belief in a higher
Ethnicity pertains to a social group within the social system that claims
shared values and traditions.
learned from birth through the processes of language acquisition and
of the following should a nurse document in the history component of a health
nurse is performing a functional assessment on an 82-year-old patient with a
recent stroke. Which of the following questions would be most important to
Answers: “Do you wear glasses?”
you able to dress yourself?”
you have any thyroid problems?”
many times a day do you have a bowel movement?”
statement is an appropriate component of one’s spirituality?
Belief in the worship of God or gods
at a specific church
personal effort to find purpose and meaning in life
Closely tied to one’s ethnic background
is the step of the nursing process that includes data collection by health
history, physical examination, and interview?
of the following is an example of a symptom?
potassium level 4.2 mEq/L
A temperature of 100 degrees F
first step in understanding the health care needs of another person is:
identifying the meaning of health to the other person.
understanding one’s own heritage-based cultural values, beliefs,
attitudes, and practices relevant to health and illness.
understanding how the health care delivery system works.
knowledgeable about the person’s social background.
of the following individuals would the nurse consider at highest risk for a
Answers: A man who jokes about death
woman who, during a past episode of major depression, attempted suicide
adolescent who has just broken up with her boyfriend and states that she would
like to kill herself
elderly man who tells the nurse that he is going to “join his wife in heaven” tomorrow
and plans to use a gun
description of who lives with a child, the method of discipline, and support
system are all related to which part of the assessment?
Review of systems
Reason for seeking care
• Question 74
interview portion of data collection collects:
woman, Mrs. H., has just entered the emergency department after being battered
by her husband. The nurse will need to get some information from her to begin
treatment. What is the best choice for an opening with this patient?
Answers: “Nancy, my name is Mrs. C.”
“Hello, Mrs. H., my name is Mrs. C. It sure is cold today!”
H., my name is Mrs. C. You sure look like you’re in pain, can I get you
H., my name is Mrs. C. I’ll need to ask you a few questions about what