Chapter 01: Evidence-Based Assessment Exam Study Guide 2022, Exams of Nursing

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Exam Study Guide 2022

Chapter 01: Evidence-Based Assessment

1. After 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: A) objective.
2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he “feels hot.” This type of data would be: C) subjective.
3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: A) data base.
4. When listening to a patient’s breath sounds, the nurse is unsure about a sound that is heard. The nurse’s next action should be to: C) validate the data by asking a coworker to listen to the breath sounds.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using: B) a set of rules.
6. Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. This is referred to as: A) intuition.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects evidence-based practice? C) EBP emphasizes the use of best evidence with the clinician’s experience.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? D) An individual with shortness of breath and respiratory distress

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9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? C) Abnormal laboratory values
10. Which critical thinking skill helps the nurse to see relationships among the data? B) Clustering related cues
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. A) nursing
12. The nursing process is a sequential method of problem solving that nurses use, and includes which steps? D) Assessment, diagnosis, outcome identification, planning, implementation,

evaluation

13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? A) Breathing, pain, sleep
14. Which of these would be formulated by a nurse using diagnostic reasoning? C) Diagnostic hypothesis
15. Barriers to incorporating evidence-based practice (EBP) include: A) nurses’ lack of research skills in evaluating quality of research studies.
16. What is the step of the nursing process that includes data collection by health history, physical examination, and interview? D) Assessment
17. During a staff meeting, nurses discuss the problems with accessing research studies in order to incorporate evidence-based clinical decision making into their practice. Which

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suggestion by the nurse manager would best help this problem? D) Teach the nurses how to conduct electronic searches for research studies.

18. When reviewing concepts of health, the nurse recalls that components of holistic health include which of these? D) Holistic health views the mind, body, and spirit as interdependent.
19. The nurse recognizes that the concept of prevention in describing health is essential because: C) prevention places emphasis on the link between health and personal behavior.
20. The nurse is reviewing the components of the nursing process. Which statement about nursing diagnoses is true? C) They are clinical judgments about a person’s response to an actual or potential health state.
21. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: D) 2 ´ 5 cm scar present on the right lower forearm.
22. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? C) A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health
23. Which situation is most appropriate for the nurse to perform a focused or problem- centered history? D) A patient in an outpatient clinic has cold and flu-like symptoms
24. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: A) collect a follow-up data base and then check her blood pressure.
25. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite

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severe. How would the nurse proceed with the data collection? B) Simultaneously ask history questions while performing the examination and initiating life- saving measures.

26. A 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: D) provide culturally sensitive and appropriate care.
27. In the health promotion model, the focus of the health professional includes: D) helping the consumer choose a healthier lifestyle.
28. The nurse is classifying nursing diagnoses. Which of these would be considered a risk diagnosis? C) Identifying potential problems the individual may develop
29. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? C) Evaluate the individual’s condition and compare actual outcomes with expected outcomes.
30. Which statement best describes a proficient nurse? A proficient nurse is one who: D) understands a patient situation as a whole rather than a list of tasks and sees long-term goals for the patient.

MATCHING Put the following patient situations in order according to level of priority.

B) A teenager who was stung by a bee during a soccer match is having trouble breathing. C) An older adult with a urinary tract infection is also showing signs of confusion and agitation. A) A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.

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1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. A) Inspiratory wheezes noted in left lower lobes C) Non productive cough E) Patient reports dyspnea upon exertion F) Rate of respirations 16 breaths per minute

Chapter 02: Cultural Competence: Cultural Care

1. The nurse is reviewing the development of culture. Which statement is correct regarding the development of one’s culture? Culture is: B) learned through language acquisition and socialization.
2. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? D) Culture adapts to specific environmental factors and available natural resources.
3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating “the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society” reflects which term? C) Culture
4. When discussing the use of the term “subculture,” the nurse recognizes that it is best described as: D) identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fasting growing population is: A) Hispanic.

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6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance.
7. The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? “The caregiver: D) understands and attends to the total context of the patient’s situation.”
8. The nurse recognizes that an example of a person who is heritage consistent would be a: B) woman who follows the traditions that her mother followed regarding meals.
9. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? C) “Ethnicity pertains to a social group within the social system that claims shared values and traditions.”
10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one’s spirituality? C) A personal effort to find purpose and meaning in life
11. 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 degree. 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? A) Assimilation
12. The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? B) “Do you mostly participate in the religious traditions of your family?”
13. A physician in the clinic is frequently bothered when patients arrive late for appointments. The physician is so irritated by this behavior that he often finds it hard to provide appropriate care to these individuals. What should he do first in trying to overcome this difficulty?

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D)

Examine his own culturally based values, beliefs, attitudes, and practices.

14. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican- Americans: B) consider these symptoms a part of normal living, not symptoms of ill health.
15. 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 of illness? B) Biomedical
16. An Asian-American woman is experiencing diarrhea, which is felt to be “cold” or “yin.” The nurse expects that the woman is likely to try to treat it with: A) foods that are “hot” or “yang.”
17. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects “health” in an Asian with this belief? C) All aspects of the person are in perfect balance.
18. Illness is seen as a part of life’s rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the theory. A) naturalistic
19. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: B) supernatural forces.
20. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: C) may also be seeking the assistance of a shaman or medicine man.

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21. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: C) further assess the patient’s cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.
22. A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurse’s best course of action? D) It is unclear what is happening with this patient, so the nurse should perform an assessment in both the physical and the psychosocial realms.
23. Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of the following is a true statement regarding pain? B) Nurses need to recognize that many cultures practice silent suffering as a response to pain.
24. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.
25. During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? “Spirituality is: D) that which arises out of each person’s unique life experience and his or her personal effort to find purpose in life.”
26. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development.
27. 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 house 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 again. She states that this is just because she doesn’t know how to speak perfect English. This woman could be experiencing:

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A)

culture shock.

28. After a symptom is recognized, the first effort at treatment is often self-care. The nurse recognizes that which of the following statements about self-care is true? Self-care is: D) influenced by the accessibility of over-the-counter medicines.
29. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? D) The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
30. In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patients’ conditions is most consistent with a “cold” condition? D) Elderly male with gastrointestinal discomfort
31. 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 elderly American Indian patient? D) “What cultural or spiritual beliefs are important to you?”
32. There are a variety of healing beliefs and practices used by numerous subcultural groups in the United States. Which statement best explains why it is important for the nurse to be aware of alternative healing practices? D) Many folk remedies are harmless and can be used in conjunction with Western medical practices and treatments.
33. During a class on cultural practices, the nurse hears the term “cultural taboo.” Which statement illustrates the concept of a cultural taboo? C) Refusing to accept blood products as part of treatment
34. The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: D) subcultures.

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35. The nurse is reviewing concepts related to one’s heritage and beliefs. The belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: B) religion.
36. When planning a cultural assessment, the nurse should include which component?

D) Health-related beliefs

37. When reviewing culture-bound syndromes, the nurse recognizes that which condition is more common among North Americans? A) Bulimia
38. The nurse recognizes that the first step in understanding the health care needs of another person is: B) understanding one’s own heritage-based cultural values, beliefs, attitudes, and practices relevant to health and illness.
39. Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is: D) harmony with nature.

MULTIPLE RESPONSE

1. The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply. B) Select questions that are not complex. D) Touch patients within the cultural boundaries of their heritage. E) Pace questions throughout the physical examination.
2. The nurse is asking questions about a patient’s health beliefs. Which questions are appropriate? Select all that apply. A) “What is your definition of health?” C)

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“How do you describe illness?” D) “What did your mother do to keep you from getting sick?” F) “How do you keep yourself healthy?”

Chapter 03: The Interview

1. The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who 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: B) exhibiting verbal and nonverbal behavior that does not match.
2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? C) Man whose wife has just been diagnosed with lung cancer
3. The nurse makes which adjustment in the physical environment in order to promote the success of an interview? A) Reduces noise by turning off televisions and radios
4. 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? A) Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors.
5. 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.” This question is found at the phase of the interview process. D) opening or introduction
6. 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 with this patient?

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D)

“Mrs. H., my name is Mrs. C. I’ll need to ask you a few questions about what happened.”

7. During an interview, the nurse states, “You mentioned shortness of breath. Tell me more about that.” Which verbal skill is used with this statement? D) Open-ended question
8. A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? D) “Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?”
9. In using verbal responses to assist the patient’s narrative, some responses focus on the patient’s frame of reference and some focus on the health care provider’s perspective. An example of a verbal response that focuses on the health care provider’s perspective would be: D) confrontation.
10. When taking a history from a newly admitted patient, the nurse notices that he is pausing often and looking at the nurse expectantly. What would be the nurse’s best response to this behavior? A) Be silent and allow him to continue when he is ready.
11. A woman is discussing the problems she is having with her 2-year-old son. She says, “He won’t go to sleep at night, and during the day he has several fits. I get so upset when that happens.” The nurse’s best verbal response would be: B) “Fits? Tell me what you mean by this.”
12. A 17-year-old single mother is describing how difficult it is to raise a 3-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?

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C)

“It must be so hard to face this all alone.”

13. A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, “I quit smoking after my wife died 7 years ago.” However, the nurse notices an open package of cigarettes in his shirt pocket. Using confrontation, the nurse could say: D) “Mr. K., you have said that you don’t smoke, but I see that you have an open package of cigarettes in your pocket.”
14. The nurse has used interpretation regarding a patient’s statement or actions. After using this technique, it would be best for the nurse to: B) allow the patient time to confirm or correct the inference.
15. 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, the nurse’s best response would be: C) “It sounds as if you might be afraid of how your husband will respond.”
16. 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 there are many good medications to decrease the pain.” Which statement is true regarding this response? It was a: B) nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears.
17. During 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: B) “Would you like some information about the different ways a person can quit smoking?”

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18. As the nurse enters a patient’s room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, “I’m so afraid of, um, you know.” The nurse’s most therapeutic response would be to say, in a gentle manner: A) “You’re afraid you might lose your breast?”
19. A nurse is taking complete health histories on all of 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 question is an example of: C) using biased or leading questions.
20. When observing a patient’s verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: D) focus on the patient’s nonverbal behaviors because these are often more reflective of a patient’s true feelings.
21. During 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: D) uncomfortable talking about his son’s treatment.
22. 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” and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? B) Stoop down to her level and ask her about the toy she is holding.
23. During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the child’s full cooperation? D) Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.
24. A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurse’s best approach to communicating with him? B) Be totally honest with him, even if the information is unpleasant.

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25. A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? A) An aged person has a longer story to tell.
26. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers.
27. 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. The nurse’s best response to her crying would be: B) “I can see that you are sad remembering this. It is all right to cry.”
28. A female nurse is interviewing a male who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse’s knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? A) Try to relax—these behaviors are culturally appropriate for this person.
29. An American Indian woman has come to the clinic for diabetic follow-up teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? D) She is showing that she is listening carefully to what the nurse is saying.
30. The nurse has just started an assessment of a newborn child of a Vietnamese mother. Considering the mother’s cultural background, which statement is true regarding this examination? The mother: A) will be offended if the infant’s fontanel is examined.
31. 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?

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A)

“Do you take medicine?”

32. A man arrives at the clinic for an annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? D) “How has your health been since your last visit?”
33. The nurse makes this comment to a patient: “I know it may be hard, but you should do what the doctor ordered because she is the expert in this field.” Which statement is correct about the nurse’s comment? C) This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation.
34. A 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? A) A trained interpreter
35. During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, “Why haven’t you taken your insulin?” Which statement is an appropriate evaluation of this question? A) It may put the patient on the defensive.
36. The nurse is nearing the end of an interview. Which statement is appropriate at this time? B) “Is there anything else you would like to mention?”
37. During the interview portion of data collection, the nurse collects data. D) subjective
38. During an interview, the nurse would expect that most of the interview will take place at which distance? C) Social distance

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39. 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. The nurse’s best reaction would be: D) “It makes me uncomfortable when you talk that way. Please stop.”

MULTIPLE RESPONSE

1. The nurse is conducting an interview. Which of these statements is true regarding open- ended questions? Select all that apply. B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information is needed.
2. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient’s data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing.

Jarvis: Physical Examination & Health Assessment, 6th Edition

Chapter 04: The Complete Health History

Test Bank

MULTIPLE CHOICE

1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? D. To provide a data base of subjective information about the patient’s past and
2. When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient:

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B.

provided consistent information and therefore is reliable.

3. 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? D. J. M. is a 59-year-old male here for having “black stools” for the past 24 hours.
4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the best response by the nurse? A. “Can you point to where it hurts?”
5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be an appropriate response by the nurse to the woman’s statement? D. “How would you say the pain affects your ability to do your daily activities?”
6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
7. 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? B. Grav 6, Term 4, (S)Ab-2, Living 4
8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information? D. “Please describe what happens to you when you take penicillin.”
9. The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include: C. mental illness.

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10. The review of systems provides the nurse with: B. information regarding health promotion practices.
11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin? C. Denies color change.
12. 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? A. “Do you perform testicular self-examinations?”
13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? D. “I’m able to transfer myself from the wheelchair to the bed without help.”
14. 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? C. “What did you do to cope with the loss of both your husband and mother?”
15. In 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? B. Alcohol can interact with all medications and can make some diseases worse.
16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? D. “Please describe what she is doing to indicate she is having pain.”
17. During an assessment of a patient’s family history, the nurse constructs a genogram. Which statement best describes a genogram? B. A graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members

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18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? D. Reactions to previous hospitalizations
19. As part of the health history of a 6-year-old boy at a clinic for a sports physical, the nurse reviews his immunization record and notes that his last MMR (measles-mumps-rubella) vaccination was at 15 months of age. What recommendation should the nurse make? B. MMR needs to be repeated at 4 to 6 years of age.
20. In obtaining a review of systems on a “healthy” 7-year-old girl, the health care provider knows that it would be important to include the: D. limitations related to her involvement in sports activities.
21. When the nurse asks for a description of who lives with a child, the method of discipline, and support system of the child, what part of the assessment is being performed? C. Functional assessment
22. The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? D. Current health promotion activities
23. The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? C. Additional questions to include are reflective of the normal effects of aging.
24. A 90-year-old patient tells the nurse that he can’t remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: D. “Would you have your family bring in your medications?”
25. 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? B. “Are you able to dress yourself?”

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26. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? D. It helps to determine how a person is managing day-to-day activities.
27. The nurse is asking a patient for his reason for seeking care, and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? A. Chest pain
28. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? D. “This pain happens every time I sit down to use the computer.”
29. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating? D. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.
30. The nurse is performing a review of symptoms. Which of these questions are appropriate as health promotion questions to ask during this time? A. “Do you use sunscreen while outside?”
31. 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? B. “Are you a part of any religious or spiritual congregation?”
32. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? D. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”
33. 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?

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B.

“When did you come to the United States, and from what country?”

MULTIPLE RESPONSE

1. 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? Select all that apply. A. “Where is the headache pain?” C. “On a scale of 1 to 10, how bad is the pain?” D. “How often do the headaches occur?” E. “What makes the headaches feel better?”
2. 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? Select all that apply. B. “How many teeth has he lost, and when did he lose them?” C. “Is he able to tie his shoelaces?” E. “Can he tell time?”