Question 1

Which of the following is an example of an ongoing assessment?

Accepted Answer

A)  Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol) 
B)  Examining the patient's mouth at the time she complains of a sore throat 
C)  Requesting the patient to rate intensity on a pain scale at the first perception of pain 
D)  Asking the patient in detail how he will return to his normal exercise activities 
A)  Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol) 
B)  Examining the patient's mouth at the time she complains of a sore throat 
C)  Requesting the patient to rate intensity on a pain scale at the first perception of pain 
D)  Asking the patient in detail how he will return to his normal exercise activities

Question 2

The patient comes to the emergency department complaining of chest pain.What question by the nurse will encourage the patient to provide the most details about the pain?

Accepted Answer

A)  "When did your chest pain begin?" 
B)  "On a scale of 0 to 10, what is your pain level?" 
C)  "Would you please tell me more about the pain you are having?" 
D)  "Have you taken any medication for your pain?" 
A)  "When did your chest pain begin?" 
B)  "On a scale of 0 to 10, what is your pain level?" 
C)  "Would you please tell me more about the pain you are having?" 
D)  "Have you taken any medication for your pain?"

Question 3

Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies?

Accepted Answer

A)  To determine what type of therapies are acceptable to the client 
B)  To identify whether the client has a nutrition deficiency 
C)  To help you to understand cultural and spiritual beliefs 
D)  To identify potential interaction with prescribed medication and therapies 
A)  To determine what type of therapies are acceptable to the client 
B)  To identify whether the client has a nutrition deficiency 
C)  To help you to understand cultural and spiritual beliefs 
D)  To identify potential interaction with prescribed medication and therapies

Question 4

Which statement below is the best example of high-quality nursing documentation?

Accepted Answer

A)  Patient breathing is normal, no pain noted, urine output is adequate at this time. 
B)  Good strength in both lower extremities. Ambulating with walker down hall. 
C)  Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting. 
D)  Patient seems upset with wife visiting in room; will perform physical assessment at a later time. 
A)  Patient breathing is normal, no pain noted, urine output is adequate at this time. 
B)  Good strength in both lower extremities. Ambulating with walker down hall. 
C)  Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting. 
D)  Patient seems upset with wife visiting in room; will perform physical assessment at a later time.

Question 5

Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented.

Accepted Answer

A)  Provide enough chairs so the family and you are able to sit facing the client. 
B)  Introduce yourself and ask, "Dear, what name do you prefer to go by?" before asking any further questions. 
C)  After the family leaves, ask the client whether she is comfortable and willing to answer a few questions. 
D)  Ask the client whether you can talk with her while her family is watching the television. 
A)  Provide enough chairs so the family and you are able to sit facing the client. 
B)  Introduce yourself and ask, "Dear, what name do you prefer to go by?" before asking any further questions. 
C)  After the family leaves, ask the client whether she is comfortable and willing to answer a few questions. 
D)  Ask the client whether you can talk with her while her family is watching the television.

Question 6

When should the nurse make systematic observations about a patient?

Accepted Answer

A)  When the patient has specific complaints 
B)  With the first assessment of the shift 
C)  Each time the nurse gives medications to the patient 
D)  Each time the nurse interacts with the patient 
A)  When the patient has specific complaints 
B)  With the first assessment of the shift 
C)  Each time the nurse gives medications to the patient 
D)  Each time the nurse interacts with the patient

Question 7

A patient is not feeling well at home and comes to the emergency department to be evaluated.In the initial nursing interview,what is the first question the nurse would ask?

Accepted Answer

A)  "Do you live alone?" 
B)  "Are you having any pain?" 
C)  "What is your past medical history?" 
D)  "Why did you come to the hospital today?" 
A)  "Do you live alone?" 
B)  "Are you having any pain?" 
C)  "What is your past medical history?" 
D)  "Why did you come to the hospital today?"

Question 8

Which of the following is an example of the most basic motivation in Maslow's Hierarchy of Needs?

Accepted Answer

A)  Experiencing loving relationships 
B)  Having adequate housing 
C)  Receiving education 
D)  Living in a crime-free neighborhood 
A)  Experiencing loving relationships 
B)  Having adequate housing 
C)  Receiving education 
D)  Living in a crime-free neighborhood

Question 9

When conducting the patient interview,which of the following statements by the nurse are appropriate? Select all that apply.

Accepted Answer

A)  "You shouldn't be smoking cigarettes; you have already had one heart attack." 
B)  "Why don't you take your blood pressure medications? You need them to keep your blood pressure normal." 
C)  "I can see that you are in pain right now. Would you like your pain medication and then I can complete the interview a little later?" 
D)  "I am going to be completing your interview now. Is this a good time for you?" 
E)  "Have you noticed any changes in your pattern of sleeping?" 
A)  "You shouldn't be smoking cigarettes; you have already had one heart attack." 
B)  "Why don't you take your blood pressure medications? You need them to keep your blood pressure normal." 
C)  "I can see that you are in pain right now. Would you like your pain medication and then I can complete the interview a little later?" 
D)  "I am going to be completing your interview now. Is this a good time for you?" 
E)  "Have you noticed any changes in your pattern of sleeping?"

Question 10

Which of the following questions would be effective for obtaining information from a patient? Select all that apply.

Accepted Answer

A)  How did this happen to you? 
B)  What was your first symptom? 
C)  Why didn't you seek healthcare earlier? 
D)  When did you start having symptoms? 
A)  How did this happen to you? 
B)  What was your first symptom? 
C)  Why didn't you seek healthcare earlier? 
D)  When did you start having symptoms?

Question 11

A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team.The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP)and which are appropriate for a licensed practical nurse (LPN)or a registered nurse (RN).To which sources should the nurse turn find out to whom to delegate which tasks? Select all that apply.

Accepted Answer

A)  Nurse practice act of his state 
B)  American Medical Association guidelines 
C)  Code of Ethics for Nurses 
D)  ANA Scope and Standards of Practice 
A)  Nurse practice act of his state 
B)  American Medical Association guidelines 
C)  Code of Ethics for Nurses 
D)  ANA Scope and Standards of Practice

Question 12

The most obvious reason for using a framework when assessing a patient is to:

Accepted Answer

A)  Prioritize assessment data 
B)  Organize and cluster data 
C)  Separate subjective data from objective data 
D)  Identify both primary and secondary data 
A)  Prioritize assessment data 
B)  Organize and cluster data 
C)  Separate subjective data from objective data 
D)  Identify both primary and secondary data

Question 13

The nurse is performing an initial interview on a 75-year-old male.Which of the following statements by this patient indicates the need to perform a special needs assessment?

Accepted Answer

A)  "I don't go to church as much as I used to but I watch the services on TV." 
B)  "I have fallen twice at home in the past 6 months, so my wife thinks I need a walker." 
C)  "I don't eat much red meat anymore but I get my protein from other foods." 
D)  "I had a toothache but I already saw the dentist." 
A)  "I don't go to church as much as I used to but I watch the services on TV." 
B)  "I have fallen twice at home in the past 6 months, so my wife thinks I need a walker." 
C)  "I don't eat much red meat anymore but I get my protein from other foods." 
D)  "I had a toothache but I already saw the dentist."

Question 14

Which of the following examples includes both objective and subjective data?

Accepted Answer

A)  The client's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min. 
B)  The client's cholesterol is elevated, and he states he likes fried food. 
C)  The client states she has trouble sleeping and that she drinks coffee in the evening. 
D)  The client states he gets frequent headaches and that he takes aspirin for the pain. 
A)  The client's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min. 
B)  The client's cholesterol is elevated, and he states he likes fried food. 
C)  The client states she has trouble sleeping and that she drinks coffee in the evening. 
D)  The client states he gets frequent headaches and that he takes aspirin for the pain.

Question 15

What makes a nursing history different from a medical history?

Accepted Answer

A)  A nursing history focuses on the patient's responses to the health problem. 
B)  The same information is gathered in both; the difference is in who obtains the information. 
C)  A nursing history is gathered using a specific format. 
D)  A medical history collects more in-depth information. 
A)  A nursing history focuses on the patient's responses to the health problem. 
B)  The same information is gathered in both; the difference is in who obtains the information. 
C)  A nursing history is gathered using a specific format. 
D)  A medical history collects more in-depth information.

Exam 3: Nursing Process: Assessment

Which of the following is an example of an ongoing assessment?

The patient comes to the emergency department complaining of chest pain.What question by the nurse will encourage the patient to provide the most details about the pain?

Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies?

Which statement below is the best example of high-quality nursing documentation?

Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented.

When should the nurse make systematic observations about a patient?

A patient is not feeling well at home and comes to the emergency department to be evaluated.In the initial nursing interview,what is the first question the nurse would ask?

Which of the following is an example of the most basic motivation in Maslow's Hierarchy of Needs?

When conducting the patient interview,which of the following statements by the nurse are appropriate? Select all that apply.

Which of the following questions would be effective for obtaining information from a patient? Select all that apply.

The most obvious reason for using a framework when assessing a patient is to:

The nurse is performing an initial interview on a 75-year-old male.Which of the following statements by this patient indicates the need to perform a special needs assessment?

Which of the following examples includes both objective and subjective data?

What makes a nursing history different from a medical history?

Evolution of Nursing Thought Action

Critical Thinking: Nursing Process

Nursing Process: Diagnosis

Nursing Process: Planning Outcomes

Nursing Process: Planning Interventions

Nursing Process: Implementation Evaluation

Evidence-Based Practice: Theory Research

Life Span: Infancy Through Middle Adulthood

Life Span: Older Adults

Experiencing Health Illness

Stress Adaptation

Psychosocial Health Illness

The Family

Culture Ethnicity

Spirituality

Loss,Grief, Dying

Documenting Reporting

Teaching Learning

Measuring Vital Signs

Communication Therapeutic Relationships

Health Assessment

Promoting Asepsis Preventing Infection

Promoting Safety

Facilitating Hygiene

Administering Medications

Nutrition

Urinary Elimination

Bowel Elimination

Sensation,Perception, Cognition

Pain

Physical Activity Mobility

Sexual Health

Sleep and Rest

Skin Integrity-Wound Healing

Oxygenation

Circulation

Fluids,Electrolytes, Acidbase Balance

Perioperative Care

Leading Managing

Nursing Informatics

Promoting Health

Community-Home Health Nursing

Ethics Values

Legal Accountability

Holistic Healing

Filters