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NSG 3160 Exam 1 (Latest 2025 and 2026
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What type of database is most appropriate when the rapid collection of data is required and often compiled concurrently with lifesaving measures? a. Complete b. Focused c. Follow-up d. Emergency d. Emergency An emergency database includes the rapid collection of data often obtained concurrently with lifesaving measures. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up on short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. A nurse precepting a student nurse asks, "What's the most important step in the critical-thinking process?" a. Clustering subjective and objective data b. Analyzing health data c. Using evidence-based assessment techniques d. Prioritizing health concerns c. Using evidence-based assessment techniques
Evidence-based techniques are supported by research showing effectiveness of the technique that provides the safest and most current techniques to promote the health of patients. Clustering subjective and objective data is a step in the critical-thinking process, but is not the most important step. Analyzing health data is a step in the critical-thinking process, but is not the most important step. Prioritizing health concerns is a step in the critical-thinking process, but is not the most important step. What type of database is most appropriate for an individual who is admitted to a long-term care facility? a. Focused b. Complete c. Emergency d. Follow-up b. Complete A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up on short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. An emergency database includes a rapid collection of data often obtained concurrently with lifesaving measures. Which of the following is an example of objective data? a. A sore throat b. An earache c. Alert and oriented d. Dizziness c. Alert and oriented
A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An emergency database is a rapid collection of data often obtained concurrently with lifesaving measures. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. Medical diagnoses are used to evaluate the cause or etiology of the disease. A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? a. Ineffective self-health management b. Impaired gas exchange c. Readiness for enhanced spiritual well-being d. Risk for infection b. Impaired gas exchange First-level priority problems are problems that are emergent, life-threatening, and immediate. Impaired gas exchange is an emergent and immediate problem. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Ineffective self-health management is an example of a third-level priority. Second-level priority problems are problems that are next in urgency; these problems require prompt intervention to forestall further deterioration. Risk for infection is an example of a second-level priority. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Wellness diagnoses are third-level priority problems. Which of the following actions/behaviors in the critical-thinking process are important for the novice nurse to remember? (Select all that apply.) a. Disregard initial cues b. Approach assessment with a nonjudgmental attitude c. Cluster associated assessment data
d. Perform assessment in whatever manner works for you. e. Avoid making assumptions b, c, e The nurse should never make assumptions as they may bias data collection and selection of diagnoses. An important aspect to gain trust with the patient is to maintain a nonjudgmental attitude. Once all health assessment data has been collected, it is important to cluster signs and symptoms as this will help in the critical thinking and decision-making process regarding medical and nursing diagnoses. It also helps to categorize problems as the first, second, or third priority. The nurse should never disregard any cues. These are important in the critical thinking and diagnosis decision-making process. Novice nurses do not have enough experience to vary from the step-by-step process for health assessment data collection. As the nurse gains experience, he/she will learn when it's appropriate to vary the process. An example of subjective data is a. decreased range of motion. b. crepitation in the left knee joint. c. arthritis. d. left knee has been swollen and hot for the past 3 days. d. left knee has been swollen and hot for the past 3 days. Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpating. Arthritis is a medical diagnosis. An example of objective data is a. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.
a. Ask about family history of diseases. b. Ask about use of traditional, herbal, or folk remedies. c. Make sure the blood pressure cuff fits appropriately. d. Measure height and weight in a private room. b. Ask about use of traditional, herbal, or folk remedies. Failing to ask about use of traditional, herbal, or folk remedies could lead to significant drug interactions. Use of a private room is not necessary for all ethnic/cultural groups. All patients should be asked about family history of diseases. This is a necessary aspect for health assessment of all individuals. It is important to make sure the blood pressure fits appropriately for all patients. Spirituality is defined as a. a social group that claims to possess variable traits. b. participating in religious services on a regular basis. c. the process of being raised within a culture. d. a personal effort to find meaning and purpose in life. d. a personal effort to find meaning and purpose in life. Spirituality is a personal effort to find purpose and meaning in life. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Ethnicity pertains to a social group within the social system that claims to possess variable traits. Which of the following statements regarding language barriers and health care is true? a. English proficiency is associated with a lower quality of care. b. Patients with language barriers have a decreased risk for nonadherence to medication regimens. c. Standards have been identified that are important to eliminate health disparities.
d. LEP is associated with a higher quality of care. c. Standards have been identified that are important to eliminate health disparities. Title VI of the Civil Rights Act of 1964 provides people with LEP access to health care; these individuals cannot be denied health care services. The National Standards for Culturally and Linguistically Appropriate Services in Health Care are important to implement in order to improve quality of care and eliminate health disparities. LEP is associated with a lower quality of care. English proficiency is associated with a higher quality of care. Patients with language barriers have an increased risk for nonadherence to medication regimens. What is the yin/yang theory of health? a. Health exists in the absence of illness. b. Health exists when all aspects of the person are in perfect balance. c. Health exists when physical, psychological, spiritual, and social needs are met. d. Health exists when there is optimal functioning. b. Health exists when all aspects of the person are in perfect balance. In the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance. In the hot/cold theory, health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. The biomedical model of Western tradition views health as the absence of disease. In the biomedical or scientific theory, high-level wellness (or health) exists with optimal functioning of the human body. Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? a. Congruence mechanism b. Heritage consistency
b. cost less than traditional or biomedical providers. Most healers cost significantly less than healers practicing in the biomedical or scientific health care system. Most healers speak the person's native tongue. Most healers make house calls. Most health practices used by folk healers are not dangerous and are usually harmless. Which of the following symptoms is greatly influenced by a person's cultural heritage? a. Food intolerance b. Hearing loss c. Pain d. Breast lump c. Pain Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain all are embedded in a cultural context. Hearing loss is more common in whites than in blacks. The incidence of breast cancer varies with different cultural groups. Food intolerance varies with different cultural groups. For example, lactose intolerance is common in African Americans, American Indians, and Asian Americans. When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the healthcare needs of others. These discrete areas include understanding of (Select all that apply.) a. his or her own heritage. b. cultural and ethnic values. c. the heritage of the health care system. d. the heritage of the nursing profession. e. the heritage of the patient.
a, c, d, e Discrete areas of knowledge for cultural competence include understanding of one's own heritage, the heritage of the nursing profession, the heritage of the patient, and the heritage of the health care system. Understanding cultural and ethnic values is not an area of knowledge for cultural competence. When preparing the physical setting for an interview, the interviewer should a. stand next to the patient to convey a professional demeanor. b. conduct the interview at eye level and at a distance of 4 to 5 feet. c. reduce noise by turning the volume on the television or radio down. d. set the room temperature between 64° F and 66° F. b. conduct the interview at eye level and at a distance of 4 to 5 feet. Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet. The room temperature should be set at a comfortable level; a temperature between 64° F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment to reduce noise. The interviewer and the patient should be comfortably seated; standing communicates haste and assumes superiority. Which of the following statements made by the interviewer would be an appropriate response? a. "Tell me what you mean by 'bad blood.'" b. "If I were you, I would have the surgery." c. "I know just how you feel." d. "Why did you wait so long to make an appointment?" a. "Tell me what you mean by 'bad blood.'"
Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior. When addressing a toddler during the interview, the health care provider should a. use detailed explanations. b. ask the child, before the caregivers, about symptoms. c. use nonverbal communication. d. use short, simple, concrete sentences. d. use short, simple, concrete sentences. A toddler's communication is direct, concrete, literal, and set in the present. The healthcare provider should use short, simple sentences with concrete explanations. For a younger child such as a toddler, the parent will provide all or most of the history. Nonverbal communication is the primary communication method for infants. Detailed explanations would be more appropriate for a school-age child, adolescent, or adult. Nonverbal communication is the primary form of communication for which group of individuals? a. Older adults b. Infants c. Preschoolers d. Adolescents b. Infants
Nonverbal communication is the primary communication method for infants. Preschoolers' communication is direct, concrete, literal, and set in the present. Adolescents should be treated with respect; the nurse should use open, honest, professional communication. Older adults may need special considerations r/t physical limitations (e.g., adjusted pace to avoid fatigue, impaired hearing). Viewing the world from another person's inner frame of reference is called a. empathy. b. clarification. c. reflection d. sympathy a. empathy. Empathy means viewing the world from the other person's inner frame of reference. Reflection is repeating part of what the person has just said. Clarification is used to summarize the person's words or to simplify the words to make them clearer. Sympathy is a social affinity in which one person stands with another person, closely understanding his or her feelings. Parents or caregivers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms. a. 11 b. 7 c. 9 d. 5 b. 7
An older adult should be addressed by the last name; older adults may be offended by a younger person using their first names. The initial introduction should include the person's surname (unless a child) and the reason for the interview. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" is a closed-ended question. "Because so many people have already asked you questions, I will just get the information from the chart" does not allow for free expression of ideas. Which of the following is included in documenting a history source? a. Appearance, dress, and hygiene b. Documented relationship of support systems c. Reliability of informant d. Cognition and literacy level c. Reliability of informant The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history. A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about a. the patient's perception of pain. b. the nature or character of the headache. c. relieving factors. d. aggravating factors. d. aggravating factors.
Aggravating factors are determined by asking the patient what makes the pain worse. To determine the patient's perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means. The nature or character calls for specific descriptive terms to describe the pain. Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help. The CAGE test is a screening questionnaire that helps to identify a. depression. b. excessive or uncontrollable drinking. c. unhealthy lifestyle behaviors. d. personal response to stress. b. excessive or uncontrollable drinking. CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. The "review of systems" in the health history is a. a short statement of general health status. b. an evaluation of past and present health state of each body system. c. a documentation of the problem as perceived by the patient. d. a record of objective findings. b. an evaluation of past and present health state of each body system.
d. exercise and activity, leisure activities, and level of independence. a. education, financial status, and value-belief system. Functional assessment measures a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value- belief system. These areas are r/t the activity and exercise section of the functional assessment. These areas are r/t the interpersonal relationships and resources section of the functional assessment. These areas are r/t the coping and stress management section of the functional assessment. PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to a. the ability to perform activities of daily living (ADLs). b. substance use and abuse. c. pain presentation. d. severity of dementia. c. pain presentation. The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person's self-care ability including the ability to perform ADLs. The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to a. ask the patient if there is someone who could verify information. b. rephrase the same questions later in the interview. c. call a family member to confirm information.
d. review previous medical records. b. rephrase the same questions later in the interview. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corroboration of information from another individual is not within the context of the present interview. This would occur outside the context of the interview. When taking a health history from an adolescent, the interviewer should a. ask every youth about the use of condoms. b. have at least one parent present during the interview. c. ask about violence and abuse before asking about alcohol and drug use. d. interview the youth alone with a parent in the waiting area. d. interview the youth alone with a parent in the waiting area. The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (r/t injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and What information is included in greater detail when taking a health history on an infant? a. Environmental hazards b. History of present illness c. Nutritional data d. Family history
