Download Exam 3: NSG 3160 / NSG3160 (NEW2026–2027) Health Assessment Review | Qs&As and more Exams Nursing in PDF only on Docsity!
Exam 3: NSG 3160 / NSG3160 (NEW 2026–2027)
Health Assessment Review | Questions with Multiple
Choices Answers | Guaranteed Grade A- Galen
Q. Which of the following is an example of an open-ended question that the nurse may use in the interview
process? A. "Did you take your medication today?" B. "Are you a student at the local college?" C. "How have you been feeling lately?" D. "Have you ever had to undergo surgery?" ANSWERS C. "How have you been feeling lately?"
Q. Which of the following are true related to nursing diagnoses? (Select all that apply)
A. Relates contributing factors or relationships to identified health problem B. Actual or potential physiology complications related to disease or treatment C.Include descriptors and risk factors D. Describes a disease or pathology of body systems E. There are not associated legal ramifications F. Describes human response to a health problem ANSWERS A. Relates contributing factors or relationships to identified health problem C. Include descriptors and risk factors F. Describes human response to a health problem.
Q. A nurse is recieving change-of shift report for a group of assigned clients. The nurse anticipates which of
the following activities first in delivering client care using the nursing process? A. Collect and organize client data B. Set client centererd measurable and realistic goals. C. Determine effectiveness of interventions. D. Critically analyze client data to determine priorities ANSWERS A. Collect and organize client data
Q. The nurse reassess a client's temperature 45 minutes after adminstering acetaminophen. This is an
example of what type of assessment? A. Routine B. Intermittent C. Terminal D. Ongoing ANSWERS D. Ongoing
Q. A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about
a client's potential allergies during which phase of the nursing process? A. Implementation B. Assessment C. Planning D. Evaluation ANSWERS B. Assessment
Q. The nurse is measuring the drainage from a Jackson- Pruitt (JP) drain. Which of the following is
considered objective data? A. The drainage measurement is 25 mL B. The client stated that he has a pain level of 5. C. The client is reporting abdominal pain. D. The client stated, "I did not empty the drain." ANSWERS A. The drainage measurement is 25 mL
Q. A home health nurse is discussing the dangers of carbon monozide poisoning with a client. Which of the
following information should be included in the teaching? A. the lungs are damaged from carbon monoxide inhalation B. Carbon monoxide has a distinct odor, so report any unusual smells immediately. C. Water heaters should be inspected every 5 years. D. Carbon monoxide binds with the hemoglobin in the body ANSWERS D. Carbon monoxide binds with the hemoglobin in the body
Q. When reviewing the concepts of health, the nurse recalls that the components of holistic health include
which of these? A. holistic health views the mind, body, and spirit as interdependent. B. Disease originates from the external environment. C. Nurses are response for a patient's health state. D. The individual human is a closed system. ANSWERS A. holistic health views the mind, body, and spirit as interdependent.
Q. A visiting nurse is making an initial home visit for a patient who has several chronic medical problems.
Which type of database is most appropriate to collect in this setting? A. focused B. Emergency C. Follow-up D. Complete ANSWERS D. A complete database
Q. The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood bressure checks
since she changed medications 2 months ago. Which the is the most appropriate action for the nurse to take? A. Obtain a complete health history on the patient before checking her BP. B. Collect a follow up database and then check the patient's BP. C. Ask the patient to read her health record and inidicate any changes since her last visit D. Check the patient's BP ANSWERS B. Collect a follow up database and then check the patient's BP.
Q. A female nurse is interviewing a male patient who is near the same age the nurse. During the interview,
the patient makes an overtly sexual comment. Which is the best response by the nurse? A. " Oh you are too funny. Let's keep going with the interview." B. "Do you really think I would be interested?" C. "It makes me uncomfortable when you talk that way. Please stop. " D. "Stop that immediately". ANSWERS C. "It makes me uncomfortable when you talk that way. Please stop. "
Q. During an interview, the nurse would expect that most of the interview will take place at what distance?
A. public B. personal C. intimate D. social ANSWERS D. social distance
Q. When observing a patient's verbal and nonverbal communcation 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. Try to integrate the verbal and nonverbal messages and then interpret them as an average. C. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings D. Focus on the patients verbal message and try to ignore the nonverbal behaviors ANSWERS C. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings
Q. The nurse if 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? A. Do you wear glasses? B. Do you have any thyroid problems? C. Are you able to dress yourself? D. How many times a day do you have a bowel movement? ANSWERS C. Are you able to dress yourself?
Q. A patient tells the nurse that he is allergic to penicillin. What is the best response by the nurse?
A. How often have you received penicillin? B. Are you allergic to any other drugs? C. Describe what happens to you when you take penicillin. D. Ill write your allergy on your chart so you won't receive any penicillin ANSWERS C. Describe what happens to you when you take penicillin.
A 42 year olf 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. Provide culturally relevant health care C. The U..S. is becoming increasingly diverse. D. Make accurate disease diagnosis. B. Provide culturally relevant health care The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture? A. Learned through language acquisition and socialization B. A nonsepecific phenomenon and is adaptive but unnecessary C. Genetically determined on the basis of racial bakground D. Biologically determined on the basis of physical characteristics. A. Learned through language acquisition and socialization 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 of place of worship D. A connection with something larger than onself and belief in transcendence. D. A connection with something larger than onself and belief in transcendence. The nurse is asking questions about a patient's health beliefs. Which questions are appropriate? (Select all that apply) A. How do ou keep yourself Healthy? B. Does your family have a history of cancer? C. Have you ever had any surgery? D. What did your mother do to keep you from getting sick? E. How do you describe illness? F. What is your definition of health? A. How do ou keep yourself Healthy? D. What did your mother do to keep you from getting sick? E. How do you describe illness? F. What is your definition of health? Which of these techniques uses the sense of touch to assess texture, temp, moisture, and swelling when the nurse is assessing a patient? A. Palpation B. Inspection C. Auscultation D. Percussion A. Palpation The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and
pulsations? A. Auscultation B. Inspection C. Percussion D. Palpation D. Palpation The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? A. Consider this finding as normal, and proceed with the abdominal assessment. B. Decrease the amount of strength used when attempting to percuss over the abdomen C. Increase the amount of strength used when attempting to percuss over the abdomen D. Ask the patient to take deep breaths to relax the abdominal musculature C. Increase the amount of strength used when attempting to percuss over the abdomen The nurse is performing a general survey. Which action is a component of the general survey? A. Observing specific body systems while performing the physical assessment B. Observing the patient's body stature and nutritional status C. Interpreting the subjective information the patient has reported D. Measuring the patients temp, pulse, respirations, and BP. C. Interpreting the subjective information the patient has reported The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this? A. Acoid missing a falsely elevated BP B. More readily identify phase IV of the Korotkoff sounds. C. More clearly hear the Korotkoff sounds. D. Detect the presence of an auscultary gap. D. Detect the presence of an auscultary gap. When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse? A. Reflects the blood volument in the arteries during diastole B. Demonstrates elasticity of the blood vessel wall C. Typically recorded on a 0- to 2- point scale D. Is a reflection of the heart's stroke volume. D. Is a reflection of the heart's stroke volume. When evaluating the temperature of older adults the nurse should remember which aspect about an older adults body temperature? A. the body temperature of the older adult is lower than that of a younger adult B. and older adults body temperature is approximately the same as that of a young child C. body temperature depends on the type of thermometer used D. In the older adult, the body temperature varies widely because of less effective heat control mechanisms. A. the body temperature of the older adult is lower than that of a younger adult A 60 year old male patient has been treated for pneumonia for the past six weeks. He is seen today in the clinic
•The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? (Select all that apply.)
- Identify any tender areas and palpate them last.
- Warm the hands first before touching the patient.
- Use the palms of the hands to assess temperature of the skin.
- Start with light palpation to detect surface characteristics.
- For deep palpation, use one long continuous palpation when assessing the liver.
- Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps. 1,2,4, •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 and/or neglect
- Suspicion of older adult abuse and/or neglect
- Suspicion of older adult abuse and/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 Neglect Neglect is the failure of the caregiver to prevent harm and includes failure to meet basic needs such as hygiene, nutrition/hydration, clothing, shelter, and medical care. Physical abuse is when an elder is intentionally injured, assaulted, threatened with a weapon, or inappropriately restrained. Financial abuse or exploitation is the unauthorized or improper use of the elder's resources for monetary or personal benefit, profit, or gain, such as forgery, theft, or improper use of guardianship or power of attorney. is the unauthorized or improper use of the elder's resources for monetary or personal benefit, profit, or gain, such as forgery, theft, or improper use of guardianship or power of attorney. Psychological or emotional abuse includes verbal and nonverbal behavior meant to inflict fear and distress. It includes humiliation, embarrassment, controlling behavior, social isolation, and damaging/destroying property. The scenario in the question is an example neglect.
Unintentional physical neglect (despite good intentions) is the failure of a family member or caregiver to meet basic needs such as hygiene, nutrition/hydration, clothing, shelter, and medical care. The nurse is caring for a 17-year-old female patient. In which situation would the nurse screen the patient for intimate partner violence (IPV)?
- 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
- As a routine part of each health care encounter During an examination, the nurse notices a patterned 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
- Whipping from an extension cord The nurse is examining a 3-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 shins
- Bruises on the abdomen The nurse is caring for several patients. Which patient is at highest risk for Intimate Partner Violence (IPV)?
- An Asian female who speaks no English
- A female multi-racial illegal immigrant
- A non-Hispanic white female living in poverty
- A female American Indian living above the poverty line
- A female multi-racial illegal immigrant A patient reports having had 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."
- "Can you point to where it hurts?" A 59-year-old patient tells the nurse that he has Asthma. He has been having "wheezing" for the last 24 hours. How would the nurse best document his reason for seeking care?
- Summary
- Closing
- Working
- Opening or introduction
- 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, Mrs. 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."
- "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
- Open-ended question •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. Which type of verbal response focuses on the health care provider's perspective?
- Empathy
- Reflection
- Facilitation
- Confrontation
- Confrontation •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." 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 2-year-old has fits."
- "Fits? Tell me what you mean by this." •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 arms against his chest and crosses his legs. What does this change in posture suggest?
- Simply changing positions
- More comfortable in this position Incorrect
- Tired and needs a break from the interview
- Uncomfortable talking about his son's treatment
- 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" and is 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 examination.
- Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.
- Stoop down to her level and ask her about the toy she is holding. To assess a patient's abdomen by palpation, how should the nurse proceed? a. Avoid palpation of reported "tender" areas because this may cause the patient pain. b. Quickly palpate a tender area to avoid any discomfort that the patient may experience. c. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Palpation can be used for which of the following? Select all that apply. a. Position of an organ b. Size of a mass c. Density of an organ d. Deep tendon reflex e. Pulsation f. Vibration A,B,E,F The nurse is assessing a patient's skin for swelling during an office visit. What is the best technique to use to assess the patient's skin for lumps and swelling? Use the: a. fingertips because they have better tactile discrimination than the rest of the hand. b. dorsal surface of the hand because the skin is thinner than on the palms of the hand. c. ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. d. palmar surface of the hand because it is most sensitive to temperature variations. a. fingertips because they have better tactile discrimination than the rest of the hand. Evidence-based nursing practice is: a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances b. Appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices
The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea during activity. After assisting the client to bed and placing the client in high- Fowler's position, the nurse would take which immediate action?
- Administer high-flow oxygen to the client.
- Call the consulting cardiologist to report the findings.
- Prepare to administer an additional dose of furosemide.
- Obtain a set of vital signs and perform focused respiratory and cardiovascular assessments.
- Obtain a set of vital signs and perform focused respiratory and cardiovascular assessments. A client scheduled for surgery states to the nurse, "I'm not sure if I should have this surgery." Which response by the nurse is appropriate?
- "It's your decision."
- "Don't worry. Everything will be fine."
- "Why don't you want to have this surgery?"
- "Tell me what concerns you have about the surgery."
- "Tell me what concerns you have about the surgery." Which teaching method is most effective when providing health care instructions to members of specific populations?
- Teach-back
- Video instruction
- Written materials
- Verbal explanation
- Teach-back
- The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?
- A postoperative client preparing for discharge with a new medication
- A client requiring daily dressing changes of a recent surgical incision
- A client scheduled for a chest x-ray after insertion of a nasogastric tube
- A client with asthma who requested a breathing treatment during the previous shift
- A client with asthma who requested a breathing treatment during the previous shift The nurse is completing the admission assessment of a client who is intellectually disabled. Which part of the client encounter may require more time to complete?
- The history
- The physical assessment
- The nursing plan of care
- The medication reconciliation
- The history The nurse caring for a refugee considers which health care need a priority for this client?
- Access to housing
- Access to clean water
- Access to transportation
- Access to mental health care services
- Access to mental health care services The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient- controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take first?
- Document the findings.
- Attempt to arouse the client.
- Contact the primary health care provider (PHCP).
- Check the medication administration history on the PCA pump.
- Attempt to arouse the client. You are preparing to do the initial interview with a 15-year-old patient. In order to establish rapport, you: a. Begin the interview by immediately discussing the health concern. Adolescents do not want small talk and want to finish as quickly as possible. b. Begin the interview by completing the full health history and discussing drug/alcohol use. Adolescents want to finish as quickly as possible. c. Begin the interview by asking open, friendly questions about school and hobbies. Adolescents appreciate the opportunity to discuss themselves. d. Begin the interview by asking open-ended questions that explore the health history. Adolescents are knowledgeable, and you can speak to them like adults. c. Begin the interview by asking open, friendly questions about school and hobbies. Adolescents appreciate the opportunity to discuss themselves. M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse? a. "Tell me what prompted that question." b. "I will ask your physician to discuss this matter with you." c. "Let's take each day as it comes." d. "I think you should discuss that with your family." a. "Tell me what prompted that question." Which of the following are open-ended questions? Select all that apply. a. Tell me about your headaches. b. Describe your chest pain. c. Point to where the pain is. d. What do you expect from me as your nurse? e. Do you want to discuss all your options? A,B,D You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional, respectful demeanor
a. continue the assessment believing that if a patient is in pain, they will tell you. b. recognize that pain expression may vary based on culture and that all Hispanic men do not take pain medications c. recognize that pain expression may vary based on culture and ask appropriate cultural assessment questions d. recognize that men do not respond to pain the same way as women, and they may not feel pain the same way c. recognize that pain expression may vary based on culture and ask appropriate cultural assessment questions You are caring for a patient who requests that a shaman (medicine man) visit him while he is hospitalized. He would like a smudging ritual completed prior to his upcoming treatment. You know that smudging involves the burning of sage. Your best response is: a. We cannot allow that ritual in the hospital because we do not allow open flames. b. Call your shaman and have him come any time. Just make sure to close the door. c. Let's work with the shaman to determine the best way to complete the ritual in a safe manner. d. Don't worry. Dr. Smith is the best, so you have nothing to worry about. c. Let's work with the shaman to determine the best way to complete the ritual in a safe manner. You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply. a. Normal skin turgor b. Normal S1, S2 heart sounds c. Pale skin d. Tachypnea (rapid breathing) e. Tachycardia (rapid pulse) f. Clear breath sounds c. Pale skin d. Tachypnea (rapid breathing) e. Tachycardia (rapid pulse) You are working in the emergency department and receive a patient who was admitted via ambulance. The patient is alert, but the injuries are severe. What are your priorities when collecting this patient's emergency database? a. A complete health history and full physical examination b. A full list of medications, allergies, family history, and personal history c. Previously identified problems including any current treatments and health promotion d. Collect critical information as you begin lifesaving measures d. Collect critical information as you begin lifesaving measures You completed the health history and physical examination on your new admission. After completing the assessment phase of the nursing process, the next step includes which of the following? a. Interpreting clinical findings and determining a diagnosis b. Clustering cues and evaluating assessment data c. Collaborating with the patient and reviewing information d. Evaluating the information collected and determining next steps a. Interpreting clinical findings and determining a diagnosis
The mother of a 2-year-old toddler tells the nurse that her son has an ear infection. What would be the most appropriate response? a. "Maybe he is just teething, but we will look in his ears later." b. "Does he have a history of frequent ear infections? It could just be teething." c. "Are you sure he is really having ear pain and not something else?" d. "Describe what he is doing that makes you think he has an ear infection."
- Underline the signs in the following patient example.
- Highlight the reason for seeking care in the following patient example. d. "Describe what he is doing that makes you think he has an ear infection." As you complete the health history, the patient appears nervous and avoids eye contact. It is unclear whether he is a reliable source of information, and you begin to question whether he is being truthful during the interview. Your best option is: a. Continue with the interview but note the nervous appearance and avoidance of eye contact. b. Confront the patient. Let him know that you are concerned he is not a reliable source of his health information. c. Continue with the interview but ask the same question in a different way to determine reliability. d. Ask the person if there is someone else who can serve as a secondary contact to ensure information is correct. c. Continue with the interview but ask the same question in a different way to determine reliability. Which of the following are open-ended questions? Select all that apply. a. Tell me about your headaches. b. Describe your chest pain. c. Point to where the pain is. d. What do you expect from me as your nurse? e. Do you want to discuss all your options? A,B,D You are preparing to do the initial interview with a 15-year-old patient. In order to establish rapport, you: a. Begin the interview by immediately discussing the health concern. Adolescents do not want small talk and want to finish as quickly as possible. b. Begin the interview by completing the full health history and discussing drug/alcohol use. Adolescents want to finish as quickly as possible. c. Begin the interview by asking open, friendly questions about school and hobbies. Adolescents appreciate the opportunity to discuss themselves. d. Begin the interview by asking open-ended questions that explore the health history. Adolescents are knowledgeable, and you can speak to them like adults. c. Begin the interview by asking open, friendly questions about school and hobbies. Adolescents appreciate the opportunity to discuss themselves. 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, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing
