Exam 1 Review Questions

Question 1

An older adult:

1. experiences a 10-point decrease in intelligence.
2. has diminished recent and remote memory recall.
3. has a slower response time.
4. has difficulty with problem solving.

Answer 1

has a slower response time.

Response time is slower in the aging adult; it may take longer for the brain to process information and react.

Question 1

The bell of the stethoscope

1. is used for soft, low-pitched sounds
2. is used for high-pitched sounds
3. is held firmly against the skin
4. magnifies sound

Answer 1

is used for soft, low-pitched sounds

Question 2

Risk factors associated with child maltreatment include:

young parents (between 18 and 20 years of age).
family with more than four children.
a parent with chronic pain.
disabled child.

Answer 2

disabled child.

Risk factors for child maltreatment include: disabilities or mental retardation in children that increase caregiver burden; social isolation of families; parental lack of understanding of child’s needs and child development; parental history of domestic abuse, poverty, family disorganization, dissolution, and violence; lack of family cohesion, substance abuse in family; young, single nonbiological parents; poor parent-child relationships; parental thoughts and emotions supporting maltreatment behaviors; parental stress and distress (depression or mental health conditions); and community violence.

Question 2

1. Lack of emotional response
2. Loss of identity
3. Excessive well-being
4. Apprehensive from the anticipation of a danger whose source is unknown
5. Annoyed, easily provoked
6. Loss of control
7. Sad, gloomy, dejected
8. Rapid shift of emotions
9. Worried about known external dangers

Depression, Anxiety, Flat affect, Euphoria, Lability, Rage, Irritability, Fear, Depersonalization

Answer 2

1. Flat affect
2. Depersonalization
3. Euphoria
4. Anxiety
5. Irritability
6. Rage
7. Depression
8. Lability
9. Fear

Question 2

The examiner is completing an initial assesment for a pt being admitted to a long-term care facility. the pt is unable to stand for a measurement of height. To obtain this important anthropometric info, the examiner may:

1. measure the waist-to-hip circumference
2. estimate the body mass index
3. measure arm span
4. obtain a mid-upper arm muscle circumference to estimate skeletal muscle reserve

Answer 2

measure arm span

Question 3

Which of the following is true regarding language barriers and health care?

1. There are laws addressing language barriers and health care.
2. Limited English proficiency is associated with a higher quality of care.
3. English proficiency is associated with a lower quality of care.
4. Patients with language barriers have a decreased risk of nonadherence to medication regimens.

Answer 3

There are laws addressing language barriers and health care.

Title VI of the Civil Rights Act of 1964 provides people with limited English proficiency access to health care; these individuals cannot be denied health care services.

Question 3

Individuals should be seen at regular intervals for health care. The frequency of these visits:

1. is most efficient if performed on an annual basis
2. is not important. There is no recommendation for the frequency of health care
3. varies, depending on the person’s illness and wellness needs
4. is based on the practioner’s clinical experience

Answer 3

varies, depending on the person’s illness and wellness needs

Question 3

The need for increasingly larger doses of a substance to achieve the same effect that was initially experienced from using is called:

1. tolerance
2. addiction
3. abuse
4. dependence

Answer 3

tolerance

Question 3

a nosocomial infection is one that is acquired:

1. in a hospital setting
2. in a public facility
3. by the fecal-oral route
4. through airbourne contaminants

Answer 3

in a hospital setting

Question 3

To support the synthesis of maternal and fetal tissue during pregnancy, a weight gain of ______ pounds is recommended

1. 25 to 30
2. 28 to 40
3. 15 to 25
4. Recommendation depends on BMI of mother at the start of the pregnancy

Answer 3

Recommendation depends on BMI of mother at the start of the pregnancy

Question 4

When reading a medical record, you see the following notation: pt states, “i have had a cold for about a week, and now I am having difficulty breathing.” this is an example of:

1. past history
2. a review of systems
3. a functional assessment
4. a reason for seeking care

Answer 4

a reason for seeking care

Question 4

What is the biomedical model of health?

Answer 4

views health as the absence of disease.

focuses on collecting data on biophysical signs and symptoms and on curing disease

Question 5

Which of the following is the most reliable indicator for chronic pain?

Magnetic resonance imaging (MRI) results
Patient self-report
Tissue enzyme levels
Blood drug levels

Answer 5

Patient self-report

The most important and reliable indicator for chronic pain is the patient’s self-report.

Question 5

The 4 areas to consider during the general survey are:

1. ethnicity, gender, age, and socioeconomic
2. physical appearance, gender, ethnicity, and affect
3. dress, affect, nonverbal behavior, and mobility
4. physical appearance, body structure, mobility, and behavior

Answer 5

physical appearance, body structure, mobility, and behavior

Question 6

What symptom is greatly influenced by a person’s cultural heritage?

1. hearing loss
2. pain
3. breast lump
4. food intolerance

Answer 6

pain

Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain are all embedded in a cultural context.

Question 6

Women are more likely to be physically or sexually assaulted by a:

family member.
stranger.
current or former intimate partner.
friend.

Answer 6

current or former intimate partner.

Women are significantly more likely to be physically or sexually assaulted by a current or former intimate partner than by an acquaintance, family member, friend, or stranger.

Question 6

Touch should be used during the interview:

1. only with individuals from a western culture
2. as a routine way of establishing contact with the person and communicating empathy
3. only with pts of the same gender
4. only if the interviewer knows the person well

Answer 6

only if the interviewer knows the person well

Question 6

Active listening skills include all of the following except:

1. taking detailed notes during the interview
2. watching for clues in body language
3. repeating statemenets back to the person to make sure you have understood
4. exploring the person’s fears about his/her illness

Answer 6

taking detailed notes during the interview

Question 7

When interviewing pts who do not speak English or have limited proficiency, the examiner should:’

1. take advantage of family members who are readily available and willing to assist
2. use a qualified medical interpreter who is culturally literate
3. seek as much info as possible and then continue with the physical examination
4. wait until a qualified medical interpreter available before starting the interview

Answer 7

use a qualified medical interpreter who is culturally literate

Question 8

The “review of systems” in the health history is:

1. an evaluation of past and present health state of each body system.
2. a documentation of the problem as perceived by the patient.
3. a record of objective findings.
4. a short statement of general health status.

Answer 8

an evaluation of past and present health state of each body system.

The purposes of the review of systems are to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices.

Question 9

The use of euphemisms to avoid reality or to hide feelings is known as:

1. distancing language.
2. sympathetic language.
3. avoidance language.
4. ethnocentric language.

Answer 9

avoidance language.

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.

Question 9

When addressing a toddler during the interview, the health care provider should:

1. ask the child, before the caretaker, about symptoms.
2. use nonverbal communication.
3. use short, simple, concrete sentences.
4. use detailed explanations.

Answer 9

use short, simple, concrete sentences.

A toddler’s communication is direct, concrete, literal, and set in the present. The health care provider should use short, simple sentences with concrete explanations.

Question 9

A comprehensive nutritional assessment always includes:

1. anthropometric measures.
2. a direct observation of feeding and eating processes.
3. a work history.
4. a comprehensive metabolic panel.

Answer 9

anthropometric measures.

Anthropometric measures evaluate growth, development, and body composition. Examples include height, weight, waist circumference, derived weight measures (e.g., body mass index, waist to hip ratio, etc.), and triceps skinfold thickness.

Question 9

The ophthalmoscope has 5 apetures. Which aperture would be used to assess the eyes of a pt w/ undilated pupils?

1. grid
2. slit
3. small
4. large

Answer 9

small

Question 9

Pulse pressure is

1. the differences between the systolic and diastolic pressure
2. a reflection of the viscosity of blood
3. another way to express the systolic pressure
4. a measure of vasoconstriction

Answer 9

the differences between the systolic and diastolic pressure

Question 10

A patient’s complaints include bleeding gums, splinter hemorrhages of the nails, and joint pain. These complaints are symptomatic of:

1. riboflavin deficiency.
2. vitamin C deficiency.
3. vitamin B12 deficiency.
4. iron deficiency.

Answer 10

vitamin C deficiency.

Patients with vitamin C deficiency may have the following clinical manifestations: petechiae or ecchymoses, bleeding gums, joint pain, and splinter hemorrhages of the nails.

Question 10

The nutritional needs of a pt with trauma or major surgery

1. are met by fat reserves in obese individuals
2. may be 2 to 3 times greater than normal
3. can be met with IV fluids supplemented with vitamins and electrolytes
4. are met by glycogen reserves

Answer 10

may be 2 to 3 times greater than normal

Question 11

The CAGE test is a screening questionnaire that helps to identify:

unhealthy lifestyle behaviors.
personal response to stress.
excessive or uncontrollable drinking.
depression.

Answer 11

excessive or uncontrollable drinking.

CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (e.g., C = Cut down; A = Annoyed; G = Guilty; E = Eye opener).

Question 11

The health care system may help abused women by:

providing shelter from the abusive individual.
identifying abuse in the early stages.
providing financial and supportive services.
estimating the ages of bruises.

Answer 11

identifying abuse in the early stages.

The health care system can be an extremely important early point of contact. Uncovering abuse in early stages may stop the pattern of violence and avoid or minimize long-term health problems.

Question 11

An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) Scale. The nurse should:

1. reassess the pain level in 3 to 4 hours.
2. administer prescribed pain medication.
3. ask the patient to verify the pain rating.
4. use only nonpharmacologic pain relief interventions.

Answer 11

administer prescribed pain medication.

A patient with a pain score of 4 or greater (on the PAINAD scale) should receive pain intervention. Patients with dementia can be given an analgesic trial or option.

Question 13

Why is it important to match the appropriate size blood pressure cuff to the person’s arm and shape and not to the person’s age?

1. Using a cuff that is too narrow will give a false reading that is high
2. Using a cuff that is too wide will give a false reading that is low
3. Using a cuff that is too narrow will give a false reading that is low
4. Using a cuff that is too wide will give a false reading that is high

Answer 13

Using a cuff that is too narrow will give a false reading that is high

Question 14

Viewing the world from another person’s inner frame of reference is called:

1. reflection.
2. empathy.
3. clarification.
4. sympathy.

Answer 14

empathy.

Empathy means viewing the world from the other person’s inner frame of reference.

Question 14

The dorsa of the hands are used to determine:

vibration.
temperature.
an organ’s position.
fine tactile discrimination.

Answer 14

temperature.

The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration.

Question 14

Routine universal screening for domestic violence means:

1. asking all women each time they come to the health care system if they are abused
2. asking women who have injuries if they are abused
3. asking women who have symptoms of depression and PTSD if they are abused
4. asking women ages 18 to 30 years if they are abused.

Answer 14

asking all women each time they come to the health care system if they are abused

Question 14

An 18-month-old child is brought in for a health screening visit. To assess the height the child:

1. Use a tape measure
2. Use a horizontal measuring board
3. Have the child stand on the upright scale
4. Measure arm span to estimate height

Answer 14

use a horizontal measuring board

Question 15

The phase of addiction characterized by tolerance, increasing time spent in substance-related activities, unsuccessful attempts to quit, and continued use despite known harm is:

1. relief
2. withdrawal
3. dependency
4. preoccupation

Answer 15

dependency

Question 16

A nursing diagnosis is best described as:

1. a determination of the etiology of disease.
2. a pattern of coping.
3. an individual’s perception of health.
4. a concise statement of actual or potential health concerns or level of wellness.

Answer 16

a concise statement of actual or potential health concerns or level of wellness.

Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state.

Question 17

American women are most often killed by:

a known sex offender.
a male convicted of a serious crime.
an intimate male partner.
a male with a substance use problem.

Answer 17

an intimate male partner.

Women in the United States are more often killed by an intimate male partner (i.e., husband, boyfriend, or ex-husband); about 75% of women killed have been abused by the man who subsequently killed them.

Question 17

While taking a history, the patient describes a burning, painful sensation that moves around his toes and bottoms of his feet. These symptoms are suggestive of:

1. nociceptive pain
2. neuropathic pain

Answer 17

neuropathic pain

Question 18

Evidence-based nursing practice can be described as:

1. combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient’s values and circumstances
2. appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient
3. completing a literature search to find relevant articles that utilize nursing research so as to encourage nurses to use good practices
4. finding value-based resoucres to justify nursing actions when working with patients of diverse cultural background

Answer 18

combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient’s values and circumstances

Question 19

Abused women have been found to have significantly more health problems, including:

cardiovascular disease.
cancer.
chronic pain.
chronic anemia.

Answer 19

chronic pain.

Abused women have been found to have significantly more injuries. Also, abused women have more chronic health problems including neurologic, gastrointestinal, and gynecologic symptoms and chronic pain.

Question 19

A dietary practice to restrict meat on certain days such as Ash Wednesday and Fridays during Lent is an example of what type of nutritional influence?

Ethnic
Economic
Religious
Cultural

Answer 19

Religious

Meat restrictions on certain holy days is a religious influence on dietary practices for many denominations of Catholics.

Question 20

A pregnant woman explains to the examiner that she does not intend to stop drinking because severl of her friends continued to drink during pregnancy, and “nothing happened to them or their kids.” How should the examiner respond to this statement?

1. “While it’s true that there is no scientific evidence that alcohol harms the fetus, abstinence is recommended because of the physical effects on your body”
2. “No amount of alcohol has been determined to be safe for a pregnant women so I wuld like to ask you to stop drinking alcohol completely”
3. “Maybe you could cut back on your alcohol intake, at least until you’re in the 3rd trimester when the effects on the fetus are minimal
4. ‘If you can, limit yourself to only one drink per day, you will be helping yourself and your baby

Answer 20

No amount of alcohol has been determined to be safe for a pregnant women, so I would like to ask you to stop drinking alcohol completely.

Question 21

Which theory has been expanded in an attempt to study the degree to which a person’s lifestyle reflects his or her traditional heritage?

1. Behavior theory
2. Heritage consistency
3. Congruence mechanism
4. Socialization experience

Answer 21

Heritage consistency

Heritage consistency theory has been expanded in an attempt to study the degree to which a person’s lifestyle reflects his or her traditional heritage.

Question 21

.
Which of the following is included in documenting a history source?

1. Appearance, dress, and hygiene
2. Cognition and literacy level
3. Documented relationship of support systems
4. Reliability of informant

Answer 21

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.

Question 22

Nonverbal communication is the primary form of communication for which group of individuals?

1. Infants
2. Preschoolers
3. Adolescents
4. Older adults

Answer 22

Infants

Nonverbal communication is the primary form of communication method for infants.

Question 22

You have come into a pt’s room to conduct an admission interview. Because you are expecting a phone call, you stand near the door during the interview. A more appropriate approach would be to:

1. arrange to have someone page you so you can sit on the side of the bed
2. have someone else answer the phone so you can sit facing the patient
3. use this approach given the circumstances; it is correct
4. arrange for the time free of interruptions after the intial physical examination is complete

Answer 22

have someone else answer the phone so you can sit facing the patient

Question 23

While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician’s reaction. In this situation, the nurse’s verbal interpretation:

1. affects the nurse–physician relationship.
2. impedes further discussion.
3. helps the patient understand personal feelings in relation to his or her verbal message.
4. helps the nurse understand his or her own feelings in relation to the patient’s verbal message.

Answer 23

helps the patient understand personal feelings in relation to his or her verbal message.

Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient’s personal feelings in relation to the patient’s verbal message.

Question 23

The practitioner, entering the examining room to meet a patient for the first time, states: “Hello, I’m M.M., and I’m here to gather some information from your and to perform your examiniation. This will take about 30 minutes. D.D> is a student working with me. If it’s all right with you, she will remain during the examination.” Which of the following must be added in order to cover all aspects of the interview contract?

1. a statement regarding confidentiality patient costs, and the expectation of each person
2. the purpose of the examiner
3. time and place of the interview and a confidentiality statement
4. an explicit purpose of the interview and a description of the physical examination, including diagnostic studies

Answer 23

a statement regarding confidentiality patient costs, and the expectation of each person

Question 24

During the general survey part of the examination, gait is assessed. When walking the base is usually:

1. varied, depending on the height of the person
2. equal to the length of the arm
3. as wide as the shoulder width
4. half the height of the person

Answer 24

as wide as the shoulder width

Question 25

The examiner is going to assess for coarctation of the aorta. IN an individual with coarctation, the thigh pressure would be:

1. higher than in the arm
2. equal to that in the arm
3. unreleated to the arm pressure. there is no constant relationship; findings are highly individual
4. lower than in the arm

Answer 25

lower than in the arm

Question 26

Obese persons with more fat in the upper body, especially the abdomen, have:

1. gastronomic obesity.
2. gynoid obesity.
3. anthropometric obesity.
4. android obesity.

Answer 26

android obesity.

Obese persons with most of their fat in the abdomen have android (upper body) obesity. A waist to hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android obesity, which places a person at higher risk for obesity-related diseases and early mortality.

Question 28

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:

1. review previous medical records.
2. rephrase the same questions later in the interview.
3. ask the patient if there is someone who could verify information.
4. call a family member to confirm information.

Answer 28

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.

Question 29

Deep palpation is used to:

identify abdominal contents.
evaluate surface characteristics.
elicit deep tendon reflexes.
determine the density of a structure.

Answer 29

identify abdominal contents.

Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.

Question 29

What 2 sections of the child’s health history becomes separate sections because of their importance to current health status?

1. play 2 activities and rest patterns
2. prenatal and postnatal status
3. developmental and nutritional history
4. accidents/injuries and immunizations

Answer 29

developmental and nutritional history

Question 29

Why should the examiner ask about the use of medications when assessing nutritional status?

1. medication allergies are on the rise and a major health concern
2. many drugs can interact with nutritients and impair their digestion, absorption, metabolism, and utilization
3. patients readily discuss their daily use of vitamin and mineral supplements when asked
4. the use of anabolic steroids can reduce muscle size and physical performance

Answer 29

many drugs can interact with nutritients and impair their digestion, absorption, metabolism, and utilization

Question 29

What is the health history sequence?

Answer 29

1. Biographic data
2. Reason for seeking care
3. Present health or HPI
4. Past history
5. Family history
6. Review of Systems
7. ADLs

Question 30

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?

1. Ineffective self–health management
2. Risk for infection
3. Impaired gas exchange
4. Readiness for enhanced spiritual well-being

Answer 30

Impaired gas exchange

First-level priority problems are those that are emergent, life threatening, and immediate. Impaired gas exchange is an emergent and immediate problem.

Question 30

Which of the following is an appropriate recording of a a pt’s reason for seeking health care?

1. angina pectoris, duration 2 hr
2. substernal pain radiating to left axila, 1 hr duration
3. “grabbing” chest pain for 2 hr
4. pleurisy, 2 days’ duration

Answer 30

“grabbing” chest pain for 2 hr

Question 32

According to the biomedical model, a narrow definition of health is:

1. An optimal functioning of mind, body, and spirit within the environment.
2. The absence of disease.
3. The response of the whole person to actual or potential problems.
4. Prevention of disease.

Answer 32

the absence of disease.

From a biomedical perspective, health is defined as the absence of disease or elimination of symptoms and signs of disease.

Question 32

a good rule for an interviewer is to:

1. stop the pt each time something is said that is not understood
2. spend more time listening to the pt than talking
3. consistently think of your next repsonse so the pt will know you understand him
4. use “why” questions to seek clarification of unusual symptoms or behavior

Answer 32

spend more time listening to the pt than talking

Question 32

What is the holistic health model?

Answer 32

assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment

Question 33

Each culture has its own healers who usually:

1. speak at least two languages.
2. own and operate specialty community clinics.
3. cost less than traditional or biomedical providers.
4. recommend folk practices that are dangerous.

Answer 33

cost less than traditional or biomedical providers.

Most healers cost significantly less than healers practicing in the biomedical or scientific health care system.

Question 33

Which of the following has been found to influence pain sensitivity in women?

1. Age
2. Hormonal changes
3. Parity
4. Weight

Answer 33

Hormonal changes

Gender differences are influenced by societal expectation, hormones, and genetic makeup. Hormonal changes are found to have strong influences on pain sensitivity for women.

Question 34

Which of the following are examples of intimate partner violence?

1. An ex-boyfriend stalks his ex-girlfriend
2. Marital rape
3. Hitting a date
4. All of above

Answer 34

all of the above

Question 35

A major characteristic of dementia is:

1. impairment of short- and long-term memory
2. hallucinations
3. sudden onset of symptoms
4. substance-induced

Answer 35

impairment of short- and long-term memory

Question 36

The nurse is leading a discussion of the planned activities for the day at an adult living center and states, “ We will be having snacks at 9:30 and lunch will be at noon” One of the participants responds in a very monotone manner, “Snacks at 9:30, lunch at noon.” The pt is exhibiting signs of:

1. echolalia
2. confabulation
3. flight of ideas
4. neologisms

Answer 36

echolalia

Question 37

PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:

1. severity of dementia.
2. substance use and abuse.
3. symptoms.
4. the ability to perform activities of daily living (ADLs).

Answer 37

symptoms.

The eight critical characteristics of any symptom reported in the history of the present illness are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient’s perception.

Question 37

What information is included in greater detail when taking a health history on an infant?

1. nutritional data
2. history of present illness
3. family history
4. environmental hazards

Answer 37

nutritional data

The amount of nutritional information needed depends on the child’s age; the younger the child is the more detailed and specific the data should be.

Question 37

One of the most frequently abused prescription opioid pain medications is:

1. oxycodone.
2. meperidine.
3. morphine.
4. propoxyphene.

Answer 37

oxycodone.

The three most frequently abused prescription opioid pain relievers are products using oxycodone, hydrocodone, and methadone.

Question 37

On a pt’s second day in an acute care hospital, the pt complains about the “bugs” on the bed. The bed is clean. This would be an example of altered:

1. thought process
2. orientation
3. perception
4. higher intellectual function

Answer 37

perception

Question 37

Body weight as a percentage of ideal body weight is calculated to assess for malnutrition. Severe malnutrition is diagnosed when current body weight is:

1. 80-90% of ideal weight
2. 70-80% of ideal weight
3. less than 70% of ideal body weight
4. 120% of ideal body weight

Answer 37

less than 70% of ideal body weight

Question 38

Aphasia is best described as:

1. a language disturbance in speaking, writing, or understanding.
2. the impaired ability to carry out motor activities despite intact motor function.
3. the impaired ability to recognize or identify objects despite intact sensory function.
4. a disturbance in executive functioning (planning, organizing, sequencing, abstracting).

Answer 38

a language disturbance in speaking, writing, or understanding.

Aphasia is a language disturbance. Apraxia is an impaired ability to carry out motor activities despite intact motor function. Agnosia is an impaired ability to identify objects correctly despite intact sensory function. A disturbance in executive functioning is a cognitive disturbance. Dementia is the development of multiple cognitive deficits with both memory impairment and a cognitive disturbance.

Question 38

select the best description of “review of systems” as part of the health history

1. the evaluation of the past and present health state of each body system
2. a documentation of the problem as described by the pt
3. the recording of the objective findings of the practioner
4. a statement that describes the overall health state of the pt

Answer 38

the evaluation of the past and present health state of each body system

Question 40

Dehydration and malnutrition can be manifestations of ________________ in the elderly.

intimate partner violence
physical abuse
neglect
psychological abuse

Answer 40

neglect

Neglect in an elderly person can manifest with symptoms of dehydration and malnutrition. Neglect (physical) is defined as failure to provide basic goods and services such as food, shelter, health care, and medications.

Question 42

Which of the following is considered an example of objective data?

Alert and oriented
Dizziness
An earache
A sore throat

Answer 42

Alert and oriented

Objective data is what the health professional observes; level of consciousness and orientation are observations.

Question 43

An example of an open-ended question or statement is:

1. “Tell me about your pain.”
2. “On a scale of 1 to 10, how would you rate your pain?”
3. “I can see that you are quite uncomfortable.”
4. “You are upset about the level of pain, right?”

Answer 43

“Tell me about your pain.”

Open-ended questions and statements ask for narrative information; they state the topic to be discussed, but only in general terms. This type of question encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen.

Question 43

Various parts of the hands are used during palpatation. The part of hte hand used for the assessment of vibration is (are) the:

1. fingertips
2. index finger and thumb in opposition
3. dorsum of the hand
4. ulnar surface of the hand

Answer 43

ulnar surface of the hand

Question 44

Spirituality is defined as:

1. participating in religious services on a regular basis.
2. a personal effort to find meaning and purpose in life.
3. the process of being raised within a culture.
4. a social group that claims to possess variable traits.

Answer 44

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.

Question 46

The behavioral checklist by Jellinek, Evans, and Knight, which is completed by a parent, is used to assess the mental status of:

1. infants
2. children 1-5 years of age
3. children 7-11 years of age
4. adolescents

Answer 46

children 7-11 years of age

Question 47

When performing percussion, the examiner:

1. strikes the flank area with the palm of the hand.
2. strikes the stationary finger at the distal interphalangeal joint.
3. strikes the stationary finger at the proximal interphalangeal joint.
4. taps fingertips over bony processes.

Answer 47

strikes the stationary finger at the distal interphalangeal joint.

To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed).

Question 48

The ability to lay down new memories is part of the assessment of cognitive functions. ONe way to accomplish this is by:

1. noting whether the pt completes a thought w/o wandering
2. a test of general knowledge
3. a description of past medical history
4. use of the 4 unrelated words test

Answer 48

use of the 4 unrelated words test

Question 49

Cultural diversity is currently considered when discussing health assesment and care. From a nursing perspective, the most accurate description of this phenomenon is:

1. nursing is inherently a transcultural phenomenon. The process of helping people involves at least 2 people having different cultural orientations
2. a consideration when the nurse is caring for someone identified as a minority among the population
3. the consderation of the needs of the population of the US that does not have European ancestry
4. an area that has always been of consideration to nursing and is included in most nursing curricula

Answer 49

nursing is inherently a transcultural phenomenon. The process of helping people involves at least 2 people having different cultural orientations

Question 49

During a pt interview, you recognize the need to use interpretation. This verbal response:

1. Is the same as clarification
2. is a summary of a statement made by a pt
3. is used to focus on a particular aspect of what the pt has just said
4. is baed on the interviewer’s inference from the data that have been presented

Answer 49

is based on the interviewer’s inference form the data that have been presented

Question 50

Which assessment fidning indicates nutrition risk?

1. BMI = 24
2. serum albumin = 2.5 g/dL
3. current weight = 200 lbs
4. BMI = 19

Answer 50

serum albumin = 2.5 g/dL

Question 51

To perform an accurate assessment of respirations, the examiner should:

1. inform the person of the procedure and count for 1 minute.
2. count for 15 seconds while keeping fingers on the pulse and then multiply by four.
3. count for 30 seconds after completing a pulse assessment and multiply by two.
4. assess respirations for a full 2 minutes if an abnormality is suspected.

Answer 51

count for 30 seconds after completing a pulse assessment and multiply by two.

Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment.

Question 51

During an initial interview, the examiner says, “Mrs.J., tell me what you do when your headaches occur.” With this question, the examiner is seeking information about:

1. the pt’s perception of the problem
2. aggravating or relieving factors
3. the frequency of the problem
4. the severity of the problem

Answer 51

aggravating or relieving factors

Question 52

Specialized nerve endings that are designed to detect painful sensations are:

1. synapses.
2. dorsal horns.
3. nociceptors.
4. C fibers.

Answer 52

nociceptors.

Nociceptors are specialized nerve endings designed to detect painful sensations from the periphery and transmit them to the central nervous system.

Question 54

Although a full mental status examination may not be required, you must be aware of th 4 main headings of the assessment while while performing the interview an and physical examination. These headings are:

1. mood, affect, conciousness, and orientation
2. memory, attention, though content, and perceptions
3. language, orientation, attention, and abstract reasoning
4. appearance, behavior, cognition, and thought processes

Answer 54

appearance, behavior, cognition, and thought processes

Question 55

Write a narrative account of a mental status assessment with normal findings.

Answer 55

Patient is dressed and groomed appropriately for season and setting. Posture is erect, with no involuntary movements. Oriented to time, person, and place. Recent and remote memory intact. Affect and verbral resonses appropriate. Perceptions and thought processes logical and coherent.

Question 56

A major characteristic of dementia is:

impaired short-term and long-term memory.
hallucinations.
sudden onset of symptoms.
cognitive deficits that are substance-induced.

Answer 56

impaired short-term and long-term memory.

Dementia is the presence of cognitive deficits; the deficits include memory impairment (impaired ability to learn new information or to recall previously learned information

Question 57

when a person presents with acute pain of the abdomen, after the initial examination, it is best to withhold anagelsic until diagnostic testing is completed and a diagnosis is made

1. true
2. false

Answer 57

false

Question 58

When preparing the physical setting for an interview, the interviewer should:

1. set the room temperature between 64 and 66° F.
2. reduce noise by turning the volume on the television or radio down.
3. conduct the interview at eye level and at a distance of 4 to 5 feet.
4. stand next to the patient to convey a professional demeanor.

Answer 58

conduct the interview at eye level and at a distance of 4 to 5 feet.

The room temperature should be set at a comfortable level; a temperature between 64 and 66° F is too cool.Turn off the television or radio and any unnecessary equipment to reduce noise.The interviewer and patient should be comfortably seated; standing communicates haste and assumes superiority.

Question 59

The balance between nutrient intake and nutrient requirements is described as:

1. undernutrition
2. malnutrition
3. nutritional status
4. overnutrition

Answer 59

nutritional status

Question 60

Amplitude is:

1. the intensity (soft or loud) of sound.
2. the length of time the note lingers.
3. the number of vibrations per second.
4. the subjective difference in a sound’s distinctive overtones.

Answer 60

the intensity (soft or loud) of sound.

Amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference due to a sound’s distinctive overtones.

Question 60

Data collection for the general survey begins:

1. at the first encounter.
2. at the beginning of the physical examination.
3. while taking vital signs.
4. during the mental status examination.

Answer 60

at the first encounter.

The general survey is initiated at the first encounter with the patient.

Question 61

One way to assess cognitive function and to detect dementia is with:

1. the proverb interpretation test
2. the mini-cog test
3. the denver II
4. the older adult behavior checklist

Answer 61

the mini-cog test

Question 63

When assessing an injury on a child, which of the following should be considered?

1. the child’s developmental level
2. the child’s medical and medication history
3. the history of how the injury occurred
4. all of the above

Answer 63

all of the above

Question 64

When reviewing the lab report (shown below) of a pt, the examiner realizes the pt is demonstrating:

• serum albumin = 4.0 g/dL
• serum tranferrin = 200 mg/dL
• serum prealbumin = 9 mg/dL

1. no evidence of protein depletion
2. mild visceral protein deficiency based on the serum albumin
3. moderate protein depletion based on the serum albumin
4. moderate protein loss on the serum prealbumin

Answer 64

moderate protein loss on the serum prealbumin

Question 66

Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand:

1. the logic of the traditional belief systems.
2. the beliefs of the patient’s family.
3. their personal belief models.
4. the risk of disease in the patient’s ethnic group.

Answer 66

the logic of the traditional belief systems.

Question 67

Risk factors for intimate partner homicide include:

1. abuse during pregnancy
2. victim substance abuse
3. victim unemployement
4. history of victim childhood sexual assault

Answer 67

victim unemployment

Question 69

Which of the following is considered when preparing to examine an older adult?

1. Base the pace of the examination on the patient’s needs and abilities.
2. Avoid physical touch to offset making the older adult uncomfortable.
3. Be aware that loss will result in poor coping mechanisms.
4. Confusion is a normal, expected finding in an older adult.

Answer 69

Base the pace of the examination on the patient’s needs and abilities.

The examination pace should be adjusted to meet the possible slowed pace of the aging person.

Question 70

Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:

1. education, financial status, and value-belief system.
2. exercise and activity, leisure activities, and level of independence.
3. family role, interpersonal relations, social support, and time spent alone.
4. stressors, coping mechanisms, and change in past year.

Answer 70

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.

Question 72

Which alcohol screening test is specifically design for use in older adults?

1. CAGE (Cutdown, Annoyed, Guilty, Eye opener)
2. TWEAK (Tolerance, Worry, Eye-opener, Amnesia, and Kut down)
3. AUDIT (Alcohol Use Disorders Identification Test)
4. MAST-G (Short Michigan Alcohol Screening Test–Geriatric Version)

Answer 72

MAST-G (Short Michigan Alcohol Screening Test–Geriatric Version)

The Short Michigan Alcohol Screening Test–Geriatric Version (SMAST-G) questionnaire is for older adults who report social or regular drinking of any amount of alcohol. Older adults have specific emotional responses and physical reactions to alcohol, and the 10 questions with yes/no responses address these factors. The TWEAK questions are a combination of items of two other questionnaires that help identify at-risk drinking in women, especially pregnant women. TWEAK has questions based on tolerance, worry, eye-opener, amnesia, and kut down. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire detects less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders. It is useful in primary care settings, with adolescent and older adults. The AUDIT covers three domains: alcohol consumption, drinking behavior or dependence, and adverse consequences from alcohol.

Question 72

Normal age-related findings in the lower extremities of an 80 year old woman would be

1. crepitus
2. joint swelling
3. diminished strength bilaterally
4. unilateral muscle atrophy

Answer 72

diminished strength bilaterally

Question 73

you have reason to question the reliability of the information being provided by a pt. one way to verify the reliability within the context of the interview is to:

1. rephrase the same questions later in the interview
2. review the pt”s previous medical records
3. call the person identified as emergency contact to verify data provided
4. provide the pt w/ a printed history to complete and then compare the data provided

Answer 73

rephrase the same questions later in the interview

Question 75

A full mental status examination should be completed if the patient:

has a change in behavior and the family is concerned.
develops dysphagia.
is newly diagnosed with type 2 diabetes mellitus.
complains of insomnia.

Answer 75

has a change in behavior and the family is concerned.

A full mental status examination is indicated if there is any abnormality in affect or behavior, and in the following situations: family members concerned about a person’s behavioral changes; brain lesions; aphasia; or symptoms of psychiatric mental illness, especially with acute onset.

Question 76

The mental status examination:

1. should be completed at the end of the physical examination.
2. will not be affected if the patient has a language impairment.
3. is usually not assessed in children younger than 2 years of age.
4. assesses mental health strengths and coping skills and screens for any dysfunction.

Answer 76

assesses mental health strengths and coping skills and screens for any dysfunction.

The purpose of the mental status examination is to assess mental health strengths and coping skills and to screen for any dysfunction.

Question 77

When the practitioner enters the examining room, the infant pt is asleep. The practitioner woujld best start the examination with

1. height and weight
2. blood pressure
3. heart, lung, and abdomen
4. temperature

Answer 77

heart, lung, and abdomen

Question 78

At the conclusion of the eamination, the examiner should:

1. document findings before leaving the examining room
2. have findings confirmed by another practioner
3. relate objective findings to the subjective findings for accuracy
4. summarize findings to the pt

Answer 78

summarize findings to the pt

Question 79

A female patient asks the nurse about the safe use of alcohol before and during pregnancy. The best response by the nurse is to instruct the patient to:

1. talk about alcohol use with the physician.
2. avoid alcohol before conception and during pregnancy.
3. reduce alcohol intake before pregnancy and to avoid alcohol after a positive pregnancy test.
4. limit alcoholic beverages to 2 or fewer drinks per week during pregnancy.

Answer 79

avoid alcohol before conception and during pregnancy.

No amount of alcohol has been determined safe for pregnant women. All women contemplating pregnancy and who are pregnant should be screened for alcohol use, and abstinence should be recommended.

Question 81

What type of pain is short and self-limiting and dissipates after the injury heals?

Chronic
Persistent
Acute
Breakthrough

Answer 81

Acute

Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals.

Question 82

ILLNESS may be described as an imbalance of hot/cold among people of:

1. asian-american heritage
2. afircan-american heritage
3. hispanic-american heritage
4. american-indian heritage

Answer 82

hispanic-american heritage

Question 84

A woman seeks medical attention for a cut made by a knife during a physical assault. The health care provider would document the cut as an:

ecchymosis.
incision.
avulsion.
abrasion.

Answer 84

ncision.

An incision is a cut or wound made by a sharp instrument. An ecchymosis is hemorrhagic spot or blotch in the skin or mucous membrane that forms a nonelevated, rounded or regular, blue or purplish patch. An avulsion is the tearing away of a structure or part. An abrasion is a wound cause by rubbing the skin or mucous membrane.

Question 85

Which of the following statements about mental status testing of children is correct?

1. The results of the Denver II screening test are valid for white, middle-class children only.
2. The behavioral checklist is useful to assess children who are 3 to 5 years of age.
3. Abnormal findings are usually related to not achieving an expected developmental milestone.
4. Input from parents and caretakers is discouraged when assessing psychosocial development.

Answer 85

Abnormal findings are usually related to not achieving an expected developmental milestone.

Abnormalities in mental status in children are often problems of omission; the child does not achieve a milestone that is expected.

Question 86

Name and describe the 4 different databases

Answer 86

• Complete (or total health) database **- **a complete health history and a full physical examination.
• Focused (or problem-centered) database - used for a limited or short-term problem. It is smaller in scope and more targeted than the complete database.
• Follow-up database** - **used in all settings to monitor progress on short-term or chronic health problems
• Emergency database - rapid collection of data, often occurs while performing lifesaving measures

Question 87

A common error in blood pressure measurement includes:

1. taking the blood pressure in an arm that is at the level of the heart.
2. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
3. deflating the cuff about 2 mm Hg per heart beat.
4. using a blood pressure cuff whose bladder length is 80% of the arm circumference.

Answer 87

waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.

Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure related to venous congestion in the forearm.

Question 88

Patients should be instructed to consume alcohol in moderation. To consume at a moderate drinking pattern, a female should be instructed to consume no more than:

two drinks per day.
one drink per day.
three drinks per week.
six drinks per week.

Answer 88

An adult should be instructed that alcohol intake should be moderate. Recommendations for moderate drinking patterns for men is 2 or fewer drinks per day; for women the recommendation is 1 or fewer drinks per day.

Question 90

When taking a health history for a child, what information, in addition to that for an adult, is usually obtained

1. coping and stress management
2. a review of immunizations received
3. environmental hazards
4. hospitalization history

Answer 90

a review of immunizations received

Question 91

When taking a health history from an adolescent, the interviewer should:

]

1. ask about violence and abuse before asking about alcohol and drug use.
2. have at least one parent present during the interview.
3. interview the youth alone with a parent in the waiting area.
4. ask every youth about the use of condoms.

Answer 91

interview the youth alone with a parent in the waiting area.

The adolescent interview during the health history should be with the youth alone; the parent(s) may wait in the waiting area and complete other past health questionnaire forms.

Question 92

The best description of the pitch of a sound wave obtained by percussion is:

1. The intensity of the sound
2. The number of vibrations per second
3. The length of time the note lingers
4. The overtones of the note

Answer 92

The number of vibrations per second

Question 94

Increased bruising and bleeding in the elderly may be related to which of the following?

Thinning of the skin
A reduction in the integrity of blood vessels
Ingestion of nonsteroidal antiinflammatory drugs
Decreased fluid intake

Answer 94

Ingestion of nonsteroidal antiinflammatory drugs

Certain medications (such as nonsteroidal antiinflammatory drugs) increase the risk for bruising or bleeding complications.

Question 96

A patient who was recently diagnosed with a seizure disorder plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient’s:

thought process.
judgment.
perception.
intellect.

Answer 96

judgment.

To assess judgment in the interview, the nurse should notice what the person says about job plans, social or family obligations, and plans for the future. Job and future plans should be realistic, and should take into account the person’s health situation.

Question 96

Which of the following is a forensic term that is related to “purpura” but is not related to blunt force trauma?

1. wound
2. incision
3. ecchymosis
4. bruise

Answer 96

ecchymosis

Question 97

Select the finding that most accurately describes the appearance of a patient

1. tense posture and restless activity. clothing clean, but not appropriate for season (e.g., pt wearing T-shirt and shorts in cold weather)
2. oriented x 3. affect appropriate for circumstances.
3. alert and responds to verbal stimuli. tearful when diagnosis discussed
4. laughing inapropriately, oriented x3

Answer 97

tense posture, and restless activity, clothing clean, but not appropriate for season (e.g., pt wearing t-shirt and shorts in cold weather)

Question 98

A patient reports consuming approximately 2000 calories per day. For a healthy diet, the patient should:

1. eat at least 4 cups of fruits and 4½ cups of vegetables per day.
2. consume less than 100 mg per day of cholesterol.
3. consume 6 ounces of whole-grain products per day.
4. keep fat intake to 5% of total calories.

Answer 98

consume 6 ounces of whole-grain products per day.

On a 2000 calorie per day diet, the person should consume 3 servings (6-ounce equivalents) or more of whole grain products per day and 3 servings of other enriched grain products.

Question 99

If the patient has a drinking problem, which statement by the nurse is most appropriate?

1. “Your alcohol consumption is not that bad. You only need to cut down on the amount by only drinking on the weekend.”
2. “I want you to record how much you drink over the next 2 to 3 months. This will help you to determine if you have a drinking problem.”
3. “If you continue to drink, you might develop serious health problems. It is up to you to find help and the way to quit.”
4. “I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help.”

Answer 99

“I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help.”

If the health care provider determines the patient has an alcohol use disorder, the health care provider should state this conclusion and recommendation clearly. In addition, the health care provider should relate to the person’s concerns and medical findings if present.

Question 101

With older adults, what is the best approach to take with the interview?

1. proceed in a more organized and concise manner
2. consider the fatigue of the aging person and break the interview into shorter segments
3. ask a family member to complete some of the records while moving ahead with the interview
4. raise your voice if the pt does not appear to hear you

Answer 101

consider the fatigue of the aging person and break the interview into shorter segments

Question 102

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:

1. memory, attention, thought content, and perceptions.
2. language, orientation, attention, and abstract reasoning.
3. appearance, behavior, cognition, and thought processes.
4. mood, affect, consciousness, and orientation.

Answer 102

appearance, behavior, cognition, and thought processes.

The four main components of a full mental status examination are appearance, behavior, cognition, and thought processes.

Question 103

Discuss special considerations when interviewing the older adult

Answer 103

• Always address them by their last name
• May need to break up the interview into more than 1 visit
• Avoid “elderspeak”
  
  • diminutives “honey”
  • inapppropriate plural pronouns “are we ready for our interview”
  • tag questions “you would rather…”
  • shortened sentences, show speech rate
• avoid hurrying them along
• if pt has impaired hearing, face them directly and talk. DON’T shout
• Use touch to convey empathy to elder pts

Question 105

Known risk factors for child maltreatment include which of the following?

1. substance abuse
2. intimate partner violence
3. physical disability/mental retardation in the child
4. all of the above

Answer 105

all of the above

Question 107

Brusing in a non-walking or non-cruising child:

1. is a common finding from normal infant activity
2. be further evaluated for either an abusive or medical evaluation
3. is commonly seen on the buttocks
4. cannot be reported until after a full medical evaluation

Answer 107

needs to be further evaluated for either an abusive or medical explaination

Question 109

Older adults are at risk for alteration in nutritional status. From the individuals described below, select the individuals who appear least at risk

1. an 80-year old widow who lives alone
2. a 65-year old widower who visits a senior center with a meal program 5 days a week
3. a 70-year old with poor dentition who lives with a son
4. a 73-year old couple with low income and no transportation

Answer 109

a 65-year old widower who visits a senior center with a meal program 5 days a week

Question 111

Neuropathic pain implies an abnormal:

1. degree of pain interpretation.
2. processing of the pain message.
3. transmission of pain signals.
4. modulation of pain signals.

Answer 111

processing of the pain message.

Neuropathic pain results from abnormal processing of the pain message.

Question 112

Differentiate between organic brain disorder and psychiatric mental illness

Answer 112

• organic - due brain disease of know specific organic cause
  
  • ex: delirium
• psychiatric - an organic etiology has not yet been established
  
  • ex: anxiety

Question 114

For older adults postoperative patients, poorly controlled acute pain places them at higher risk for:

1. atelectasis
2. increased myocardial oxygen demand
3. impaired wound healing
4. all of the above

Answer 114

all of the above

Question 115

Which of the following are normal expected changes with aging?

1. increase in energy needs
2. increase in body water
3. decrease in height
4. increase in AP diameter of the chest

Answer 115

decrease in height

Question 116

Select the best description of an accurate assessment of a pt’s pulse

1. Count the 15 seconds if pulse is regular
2. Begin counting with zero, count for 30 seconds
3. Count for 30 seconds and multiply by 2 for all cases
4. Count for 1 full minute; begin counting with 0

Answer 116

Begin counting with zero, count for 30 seconds

Question 118

Which of the following is an example of a pt with dysarthria?

1. When asked a question, the pt responds fluently but uses wrds incorrectly or makes up words so tht the speech may be incomprehensible
2. The word choice and grammar are approrpriate, but the sounds are distorted so speech is unintelligible
3. The pitch and volume of words are difficult and the voice may be hoarse, but language is intact
4. Comprehension is intact, but there is difficulty in expressing thoughts, with nouns and verbs begin the dominant word choices

Answer 118

The word choice and grammar are appropriate, but the sounds are distorted so speech is unintelligible

Question 119

For a patient to meet the criteria for a diagnosis of alcohol abuse, the patient must report that alcohol has repeatedly caused or contributed to:

amnesia episodes while drinking.
relationship trouble with family or friends.
needing more than three drinks to feel the effects.
one or more family members complaining about alcohol use.

Answer 119

relationship trouble with family or friends.

To meet the criteria for a diagnosis of alcohol abuse, the patient must admit that drinking alcohol repeatedly causes or contributes to one or more of the following occurring in the past 12 months: 1) risk of bodily harm (drinking and driving, operating machinery, swimming); 2) relationship trouble (family or friends); 3) role failure ((interference with home, work, or school obligations); or 4) run-ins with the law (arrests or other legal problems).

Question 121

Examples of closing the interview statements….

Answer 121

• “Is there anything else your would like to mention?”
• “Are there any questions you would like to ask?”
• “Are there any other areas I should have asked about?”
• “We have covered a number of concerns today. What would you most like to accomplish?”

Question 123

Which of the following data would be obtained as part of a nutritional screening?

1. temperature, pulse, and respiration
2. blood pressure and genogram
3. weight and nutrition intake history
4. serum creatinine levels

Answer 123

weight and nutrition intake history

Question 125

When considering cultural competence, there are discrete areas that the nurse must develop knowledge of to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.)

1. his or her own heritage.
2. cultural and ethnic values.
3. the heritage of the nursing profession.
4. the heritage of the patient.
5. the heritage of the health care system.

Answer 125

1, 3, 4, 5.

Question 127

When should the examiner use hand washing instead of an alcohol-based hand rub?

1. if the patient has an infection with Mycobacterium tuberculosis
2. if the patient has an infection with Clostridium difficile
3. if the patient has an infection with hepatitis B virus
4. if the patient is HIV positive

Answer 127

if the patient has an infection with Clostridium difficile

The examiner should use the mechanical action of soap-and-water hand washing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., Clostridium difficile or Bacillus anthracis).

Question 128

A patient denies having a drinking problem. Which of the following laboratory tests is commonly used as a biochemical marker that indicates chronic alcohol use?

1. elevated gamma-glutamyl transferase (GGT)
2. elevated serum aspartate aminotransferase (AST)
3. elevated mean corpuscular volume (MCV)
4. elevated blood alcohol content (BAC)

Answer 128

elevated gamma-glutamyl transferase (GGT)

A serum protein, gamma-glutamyl transferase (GGT) is the most commonly used biochemical marker of alcohol drinking, especially of chronic alcohol use.

Question 129

DUring the 8th and 9th decards of life, physical changes occur. Height and Weight

1. Both increase
2. Weight increases, height decreases
3. Both decreases
4. Both remains the same as during the 70s

Answer 129

Both decreases

Question 130

What occurs during transduction (the first phase of nociceptive pain)?

1. Pain signals move from the site of origin to the spinal cord
2. Pain impulse moves from the spinal cord to the brain
3. Interpretation of the pain signal by the brain
4. Neutralization of chemical mediators to decrease the perception of pain

Answer 130

Pain signals move from the site of origin to the spinal cord

Transduction is the first phase of nociceptive pain. During this phase, injured tissue releases chemicals that propagate the pain message; an action potential moves along an afferent fiber to the spinal cord.

Question 132

Which of the following statements, if made by the interviewer, would be an appropriate response?

1. “I know just how you feel.”
2. “If I were you, I would have the surgery.”
3. “Why did you wait so long to make an appointment?”
4. “Tell me what you mean by ‘bad blood’.”

Answer 132

“Tell me what you mean by ‘bad blood’.”

This response is an appropriate communication technique referred to as seeking further clarification.

Question 134

Current dietary guidelines recommend that complex carbohydrates make up ___% of total calorie intake

1. 30
2. 40
3. 60
4. 75

Answer 134

60

Question 135

The most reliable indicator of pain in the adult is:

1. degree of physical functioning
2. nonverbal behaviors
3. MRI findings
4. the pt’s self-report

Answer 135

the pt’s self-report

Question 137

The major factor contributing to the need for cultural care nursing is:

1. an increasing birth rate
2. limited access to health care services
3. demographic change
4. a decreasing rate of immigration

Answer 137

demographic change

Question 139

The sequence of an examination changes from beginning with the thorax to that of head to toe with what age child?

1. the infant
2. the preschool child
3. the school-age child
4. the adolescent

Answer 139

the school-age child

Question 140

List the 10 traps of interviewing

Answer 140

1. Providing false assurances or reassurance
2. Giving unwarranted advice
3. Using authority
4. Using avoidance language
5. Engaging or distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions

Question 142

The nurse records that the patient’s pulse is 3+ or full and bounding. Which of the following could be the cause?

1. Dehydration
2. Shock
3. Bleeding
4. Anxiety

Answer 142

Anxiety

A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise.

Question 143

Select the most complete description of database

1. subjective and objective data gathered by a health practiioner from a patient
2. objective data obtained from a patient though inspection, percussion palpalation, and auscultation
3. a summary of a pt’s record, including lab studies
4. subjective and objective data gathered from a pt plus the results of any diagnostic studies completed

Answer 143

subjective and objective data gathered from a pt plus the results of any diagnostic studies completed

Question 144

Nutritional status is best determined by:

1. serum albumin.
2. clinical manifestations.
3. triglycerides.
4. 24-hour diet recall.

Answer 144

serum albumin.

Laboratory testing is required to make an accurate diagnosis of malnutrition. Serum albumin is a common measurement of visceral protein status. Low serum albumin levels occur with protein-calorie malnutrition, altered hydration status, and decreased liver function. A serum albumin level of 2.8 to 3.5 g/dl represents moderate visceral protein depletion, and less than 2.8 g/dl denotes severe depletion.

Question 145

If a patient admits to not being able to quit drinking, having to have more drinks to get the same effect, and having withdrawal symptoms, the patient meets criteria for:

at-risk drinking.
alcohol dependence.
hazardous drinking.
harmful drinking.

Answer 145

alcohol dependence.

The criteria is met for a diagnosis of alcohol dependence if a patient admits to three or more of the following: not being able to stick to drinking limits (repeatedly going over them); not being able to cut down or stop (repeated failed attempts); showing tolerance (needing to drink a lot more to get the same effect); showing signs of withdrawal (tremors, sweating, nausea, or insomnia when trying to quit or cut down); continuing to drink despite problems (recurrent physical or psychological problems); spending a lot of time drinking (or anticipating or recovering from drinking); and spending less time on other matters (activities that have been important or pleasurable).

Question 146

The general survey consists of four distinct areas. These areas include:

1. mental status, speech, behavior, and mood and affect.
2. gait, range of motion, mental status, and behavior.
3. physical appearance, body structure, mobility, and behavior.
4. level of consciousness, personal hygiene, mental status, and physical condition.

Answer 146

physical appearance, body structure, mobility, and behavior.

The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior.

Question 147

Pain in the aging adult is considered to be

1. part of the normal degenerative process
2. percieved to a lesser degree
3. an expected finding
4. unrelated to the aging process

Answer 147

unrelated to the aging process

Question 148

Pain signals are carried to the central nervous system by way of:

perception.
afferent fibers.
modulation.
referred pain.

Answer 148

afferent fibers.

Nociceptors carry the pain signal to the central nervous system by two primary sensory (or afferent) fibers.

Question 149

Fine tactile discrimination is best achieved with the:

1. opposition of the fingers and thumb.
2. fingertips.
3. back of the hands and fingers.
4. base of the fingers.

Answer 149

fingertips.

The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass.

Question 151

Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms.

5
7
9
11

Answer 151

7

School-age children (starting at age 7) have the verbal ability to add important data to the history. The nurse should interview the parent and child together, but when a presenting symptom or sign exists, the nurse should ask the child about it first, then gather data from the parent.

Question 153

An extremely important part of the history and examination in situations of intimate partner violence or elder abuse is the:

mental status examination.
family genogram.
history of the present illness.
skin assessment.

Answer 153

mental status examination.

An extremely important part of the history and examination in cases of intimate partner violence or elder abuse is a mental status examination, both for potential head trauma and neurological symptoms and also for mental health problems.

Question 154

Mean arterial pressure is

1. the arithmetic average of systolic and diastolic pressure
2. the driving force of blood during systole
3. diastolic pressure plus 1/3 pulse pressure
4. corresponding to phase III Korotkoff

Answer 154

diastolic pressure plus 1/3 pulse pressure

Question 155

the statement, “reason for seeking care” has replaced “chief complaint.” this change is significant because:

1. “chief complaint” is really a diagnostic statement
2. the newer term allows another individual to supply the necessary information
3. the newer term incorporates wellness needs.
4. “reason for seeking care” can incorporate the history of present illness

Answer 155

the newer term incorporates wellness needs.

Question 156

What type of database is most appropriate for an individual who is admitted to a long-term care facility?

Episodic
Follow-up
Emergency
Complete

Answer 156

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.

Question 157

An example of objective data is:

1. Complaints of left knee pain.
2. Crepitation in the left knee joint.
3. Left knee has been swollen and hot for the past 3 days.
4. Report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.

Answer 157

crepitation in the left knee joint.

Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation.

Question 158

When performing indirect percussion, the stationary finger is struck:

1. At the ulnar surface
2. At the middle joint
3. At the distal interphalangeal joint
4. Wherever it is in contact with the skin

Answer 158

At the dital interphalangeal joint

Question 159

“culturally competent” implies that the nurse:

1. is prepared in nursing
2. possesses knowledge of the traditions of diverse peoples
3. applies underlying knowledge to providing nursing care
4. understands the cultural context of the pt’s situation

Answer 159

understands the cultural context of the pt’s situation

Question 160

What type of data base is most appropriate when a rapid collection of data is required and often compiled concurrently with life-saving measures?

Episodic
Follow-up
Emergency
Complete

Answer 160

Emergency

An emergency database is rapid collection of the data often obtained concurrently with lifesaving measures.

Question 161

Select the best description of an accurate assessment of a pt’s respirations

1. Count for a full minute before taking the pulse
2. Count for 15 seconds and multiply by 4
3. Count after informing the pt where you are in the assessment process
4. Count for 30 seconds after pulse assessment

Answer 161

Count for 30 seconds after pulse assessment

Question 163

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:

1. the patient’s perception of pain.
2. the nature or character of the headache.
3. aggravating factors.
4. relieving factors.

Answer 163

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.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 nature or character calls for specific descriptive terms to describe the pain.

Question 164

What changes in head circumference measurements in relation to chest measurements will occur from infancy through early childhood?

1. A newborn’s head should be about 5 cm larger than the chest circumference, but by age 2, they should be equal
2. The chest grows at a faster rate than the cranium, but at age 1, the measurements will be the same, and after age 2, the chest should be 5 cm larger
3. The newborn’s head will be 2 cm larger than the chest circumference, but bertween 6 months and 2 years, they will be about the same
4. The head and chest circumferences should be very similar, but between 6 months and 2 years, the chest size will increase and remain that way

Answer 164

The newborn’s head will be 2 cm larger than the chest circumference, but bertween 6 months and 2 years, they will be about the same

Question 165

Physical appearance includes statements that compare appearance with:

1. mood and affect.
2. stated age.
3. gait.
4. nutrition.

Answer 165

stated age.

Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features.

Question 166

List the 8 items of information that should be communicated to the patient concerning the terms or expectations of the interview

Answer 166

1. Time and place of the interview and succeeding physical examination
2. Introduction of yourself and a brief explanation of your role
3. The purpose of the interview
4. How long it will take
5. Expectation of participation for each person
6. Presence of any other people (e.g., pt’s family, other health professionals, students)
7. Confidentiality and to what extent it may be limited
8. Any costs that the pt must pay

Question 167

A pain problem should be anticipated in a cognitively impaired older adult with a history of:

1. constipation
2. peripheral vascular disease
3. COPD
4. Parkinson disease

Answer 167

peripheral vascular disease

Question 168

During an interview, a pt denies having any anxiety. the pt frequently changes position in the chair, holds his arms folded tight against his chest, and has little eye contact with the interviewer. The interviewer should:

1. use confrontation to bring the discrepancy btw verbal and nonverbal behavior to the pt’s attention
2. proceed with the interview. pts usually are truthful with a HCP
3. make a mental note to discuss the behavior after the physical examination is completed
4. proceed with the itnerview and examination as outlined on the agency assessment form. the pt’s behavior is appropriate for the circumstances

Answer 168

use confrontation to bring the discrepancy btw verbal and nonverbal behavior to the pt’s attention

Question 169

Dysphonia vs Dysarthria vs Aphasia

Answer 169

• dysphonia (voice disorder) - difficulty or discomfort in talking , with abnormal pitch or volume, due to laryngeal disease. voice sounds hoarse or whispered, but articulattion and language are still intact
• dysarthria (articulation disorder) - distorted speech sounds; speech may sound unintelligible; basic language (word choice, grammar, comprehension) intact
• aphasia - true language disturbance, defect in word choice and grammar or defect in comprehension; defect is in higher integrative language processing

Question 170

Which is the most commonly used laboratory test to identify chronic alcohol drinking?

1. blood urea nitrogen
2. liver enzyme panel
3. gamma glutamyl transferase (GGT)
4. mean corpuscular volume (MCV)

Answer 170

gamma glutamyl transferase (GGT)

Question 171

What can be determined when the nurse clusters data as part of the critical-thinking process?

1. this identifies problems that may be urgent and require immediate action by the nurse
2. this step of the process involves recognizing inconsistencies in the data
3. the nurse recognizes patterns and relationships among the data
4. risk factors can be determined so the nurse knows how to offer health teaching

Answer 171

the nurse recognizes patterns and relationships among the data

Question 173

Dietary guidelines suggest that overall fat consumption should be:

1. less than 300 mg per day.
2. between 10% and 20% of the total calorie intake.
3. between 20% and 35% of the total calorie intake.
4. mostly trans-fatty acid or saturated fat.

Answer 173

between 20% and 35% of the total calorie intake.

Total fat intake should be between 20% and 35% of calories, most from polyunsaturated or monounsaturated fats.

Question 174

Mr. B. tells you, “ Everyone here ignores me.” YOu respond, “Ignores you?” This technique is best described as:

1. clarification
2. selective listening
3. reflecting
4. validation

Answer 174

reflecting

Question 175

The Doppler technique:

1. is used to assess the apical pulse.
2. augments Korotkoff sounds during blood pressure measurement.
3. provides an easy and accurate measure of the diastolic pressure.
4. measures arterial oxygenation saturation.

Answer 175

augments Korotkoff sounds during blood pressure measurement.

The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds.

Question 175

During an interview with a pt newly diagnosed with a seizure disorder, the pt states, “I plan to be an airline pilot.” If the pt continues to have this as a career goal after teaching regarding seizure disorders have been provided, the practioner might question the pt’s:

1. thought processes
2. judgement
3. attention span
4. recent memory

Answer 175

judgement

Question 176

A patient with chronic alcohol use is most at risk for developing which of the following cardiovascular diseases?

1. Bradycardia
2. Deep vein thrombosis
3. Hypertension
4. Acute myocardial infarction

Answer 176

Hypertension

Chronic alcohol use is associated with increased risk of alcoholic cardiomyopathy, hypertension, and atrial fibrillation.

Question 178

During the intitial home visit, the pt’s temperature is noted to be 97.4. this temperature

1. cannot be evaluated without a knowledge of the person’s age
2. is below normal. The person should be assessed for possible hypothermia
3. should be retaken by the rectal route, since this best reflects core body temp
4. should be reevaluated at the next visit before a decision is made

Answer 178

cannot be evaluated without a knowledge of the person’s age

Question 179

Which of the following is true regarding cultural/racial differences in the treatment of pain?

1. White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.
2. Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals.
3. Pain modulation is more highly developed in black and Hispanic individuals.
4. Neurotransmitters are more concentrated in whites individuals than they are in black and Hispanic individuals.

Answer 179

White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.

Various studies describe how black and Hispanic patients are often prescribed less analgesic therapy than white patients, although most of these differences are small.

Question 181

Knowledge of the use of personal space is helpful for the HCP . Personal distance is generally considered to be

1. 0 - 1.5 feet
2. 1.5 - 4 feet
3. 4 - 12 feet
4. 12+ feet

Answer 181

1.5 - 4 feet

Question 182

The tympanic membrane thermometer:

1. provides an accurate measurement of core body temperature.
2. senses the infrared emissions of the cerebral cortex.
3. is not used in unconscious patients.
4. accurately measures temperature in 20 to 30 seconds.

Answer 182

provides an accurate measurement of core body temperature.

The tympanic membrane thermometer (TMT) is an accurate measurer of core body temperature.

Question 183

A medical diagnosis is used to evaluate:

a person’s state of health.
the response of the whole person to actual or potential health problems.
a person’s culture.
the cause of disease.

Answer 183

the cause of disease.

Medical diagnoses are used to evaluate the etiology (cause) of disease.

Question 184

What is the source of deep somatic pain?

1. Skin and subcutaneous tissues
2. Bones and joints
3. Pancreas
4. Intestine

Answer 184

Bones and joints

Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bones.

Question 185

The nurse would expect an older adult to have higher blood alcohol levels because older adults have:

more lean muscle mass.
an increased consumption of alcohol.
decreased liver metabolism and kidney functioning.
increased gastrointestinal motility.

Answer 185

decreased liver metabolism and kidney functioning.

Older adults have numerous characteristics that can increase the risk for alcohol use. Liver metabolism and kidney functioning are decreased, which increases the bioavailability of alcohol in the blood for longer time periods.

Question 186

At what phase duing nociception does the individual become aware of a painful sensation?

1. modulation
2. transduction
3. perception
4. transmission

Answer 186

transduction

Question 187

Student frequently sk teachers “May I ask you a question?” This is an example of :

1. An open-ended question
2. A reflective question
3. A closed question
4. A double-barreled question

Answer 187

a closed question

Question 188

The mnemonic PQRSTU is helpful for organizing the critical characteristics of a symptom. GIve an example of a question that could be asked that relates to each of the letters.

Answer 188

P - What brings it on? What were you doing when you first noticed it? Worse?

Q - How does it look, feel, sound? How intense/severe is it?

R - Where is it? Can you point to the location? Does it spread anywhere?

S - How bad is it? (on a scale of 0/10)? Is it getting better, worse, staying the same?

T - When did it first occur? How long did it last? How often does it occur?

U - What do you think this means? Is this significant to you?

Question 189

To accurately plan for discharge teaching, additional asessments may be required for the pt with aphasia. This may be accomplished by asking the pt to:

1. calculate serial 7s
2. name his/her grandkis and their b-days
3. demonstrate word comprehension by naming articles in the room or on the body as you point to them
4. interpret a proverb.

Answer 189

demonstrate word comprehension by naming articles in the room or on the body as you point to them

Question 190

Children are usually brought for health care by a parent. At about what age should the interviewwer begin to question the child himself or hersolf regarding presenting symptoms?

1. 5 years
2. 7 years
3. 9 years
4. 11 years

Answer 190

7 years

Question 191

the first step to cultural competency by a nurse is to:

1. identify the meaning of health to the patient
2. undersand how a health care delivery system works
3. develop a frame of reference as to traditional health care practices
4. understand your own heritage and its basis in cultural values

Answer 191

understand your own heritage and its basis in cultural values

Question 191

During the physical examination, your pt is diaphoretic and pale and complains of pain directly over the LUQ of the abdomen. This would be categorized as:

1. Cutaneous pain
2. Somatic pain
3. Visceral pain
4. Psychogenic pain

Answer 191

Somatic pain

Question 192

A 30-year old female reports having persistent intense pain in her right arm related to trauma sustained from a car accident 5 months ago. She states that the slightest touch or clothing can exacerbate the pain. This report is suggestive of:

1. referred pain
2. psychogenic pain
3. Complex Regional Pain I
4. cutaneous pain

Answer 192

Complex Regional Pain I

Question 193

The 24-hour recall of dietary intake

1. is an anthropometric measure of calories consumed
2. is a questionnaire or interview of everything eating within the last 24 hours
3. is the same as a food frequency questionnaire
4. is a form of food dairy

Answer 193

is a questionnaire or interview of everything eating within the last 24 hours

Question 195

Endogenous obesity is:

1. due to inadequate secretion of cortisol by the adrenal glands.
2. caused by excess adrenocorticotropin production by the pituitary gland.
3. characterized by evenly distributed excess body fat.
4. a result of excessive secretion of growth hormone in adulthood.

Answer 195

caused by excess adrenocorticotropin production by the pituitary gland.

Endogenous obesity is caused by either the administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary.

Question 196

As defined by the American Psychiatric Association DSM-IV criteria, which of the following is characterized by, for example, a college student’s (1) failure to attend class and complete assignments, (2) driving while intoxicated, (3) legal problems such as a DUI, and (4) continued use despite problem?

1. Drug dependence
2. Drug habituation
3. Relief drug use
4. Drug abuse

Answer 196

Drug Abuse

Question 197

A genogram is useful in showing information concisely. It is used specifically for:

1. past history
2. past health, specifically hospitalizations
3. family history
4. the 8 characteristics of presenting symptoms

Answer 197

family history

Question 198

Mental status assessment documents:

1. emotional and cognitive functioning.
2. intelligence and educational level.
3. artistic or writing ability in the mentally ill person.
4. schizophrenia and other mental health disorders.

Answer 198

emotional and cognitive functioning.

Mental status assessment is a systematic check of emotional and cognitive functioning.

Question 199

Because of adolescents’ developmental level, not all interviewing technkiques can be used with them. The two to be avoided are:

1. facilitation and clarification
2. confrontation and explanation
3. empathy and interpretations
4. silence and reflection

Answer 199

silence and reflection

Question 200

Mary, a 15-year old, has come for a school physical. During the interview, the examiner is told that menarche has not occurred. An explanation to be explored is:

1. nutritional deficiency
2. alcohol intake
3. smoking history
4. possible elevated blood sugar

Answer 200

nutritional deficiency

Question 202

The nurse caring for an older adult suspects elder abuse. Which action is appropriate?

1. Collect proof of abuse before notifying the authorities.
2. Confront the caretakers about the suspicion of abuse.
3. Notify the authorities of the suspected elder abuse.
4. Report the abuse if the older adult gives permission.

Answer 202

Notify the authorities of the suspected elder abuse.

The nurse is a mandatory reporter of elder abuse and should notify the authorities of suspected elder abuse.

Question 203

What is the yin/yang theory of health?

1. Health exists when all aspects of the person are in perfect balance.
2. Health exists when physical, psychologic, spiritual, and social needs are met.
3. Health exists in the absence of illness.
4. Health exists when there is optimal functioning.

Answer 203

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, psychologic, 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.

Question 204

Gynecologic problems not associated with intimate partner violence include:

1. pelvic pain
2. ovarian cysts
3. STIs
4. vaginal tearing

Answer 204

ovarian cysts

Question 205

After assesing the pt’s pulse, the practiioner determines it to be “normal”. this would be recorded as:

1. 3+
2. 2+
3. 1+
4. 0

Answer 205

2+

Question 207

The CRIES is an appropriate pain assessment tool for:

1. cognitively impaired older adults
2. children ages 2-8 years
3. infants
4. preterm and term neonates

Answer 207

preterm and term neonates

Question 208

For optimum health, infants and children up to 2 years of age should receive whole milk. What component of whole milk is essential for neurologic development?

1. Lactose
2. Pasteurized protein
3. Fortified vitamin D
4. Fat

Answer 208

Fat

Infants and children younger than 2 years of age should not drink skim or low-fat milk or be placed on low-fat diets. Fat (calories and essential fatty acids) is required for proper growth and central nervous system development.

Question 209

An example of subjective data is:

decreased range of motion.
crepitation in the left knee joint.
left knee has been swollen and hot for the past 3 days.
arthritis.

Answer 209

left knee has been swollen and hot for the past 3 days.

Subjective data is what the person says about himself or herself during history taking.

Question 211

An adult patient’s pulse is 46 beats per minute. The term used to describe this rate is:

1. tachycardia.
2. bradycardia.
3. weak and thready.
4. sinus arrhythmia.

Answer 211

bradycardia.

A heart rate of less than 50 beats per minute in an adult is bradycardia.

Question 212

While caring for a preterm infant, you are aware that:

1. inhibitory neurotransmitters are in sufficient supply by 15 weeks’ gestation
2. the fetus has less capacity to feel pain
3. reptitive blood draws have minimal long-term consequences
4. the preterm infant is more sensitive to painful stimuli

Answer 212

the preterm infant is more sensitive to painful stimuli

Question 213

Obesity in adults is defined as:

1. excess body fat placed predominately within the hips and thighs.
2. excessive body fat leading to body weight 5% above ideal.
3. a body mass index of 30 or greater.
4. overnourished.

Answer 213

a body mass index of 30 or greater.

Obesity in adults is defined as a body mass index of 30 or greater. Overweight in adults is defined as a body mass index of 25 or greater.

Question 214

Which of the following should be routinely included in evaluating a case of elder abuse?

1. corroborative interview from caregiver
2. baseline lab tests
3. testing for STIs
4. TB test

Answer 214

baseline lab tests

Question 215

Energy requirements for the aging adult decrease as a result of:

1. loss of energy.
2. eating habits.
3. loss of lean body mass.
4. decreasing body fat.

Answer 215

loss of lean body mass.

The older adult has a decrease in energy requirements due to loss of lean body mass, the most metabolically active tissue.

Question 216

When recording information for the review of systems, the interviewer must document:

1. physical findings, such as skin appearance, to support historic data.
2. “negative” under the system heading.
3. the presence or absence of all symptoms under the system heading.
4. objective data that supports the history of present illness.

Answer 216

the presence or absence of all symptoms under the system heading.

When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms, otherwise it is unknown which factors were asked.

Question 218

To examine a toddler, the nurse should:

1. allow the child to sit on the parent’s lap.
2. remove the child’s clothing at the beginning of the examination.
3. ask the child to decide whether parents or siblings should be present.
4. perform the assessment from head to toes.

Answer 218

allow the child to sit on the parent’s lap.

A toddler should be sitting up on the parent’s lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child that is 11 or 12 years old to decide whether parents or siblings should be present. The sequence for a toddler should start with nonthreatening areas first; save distressing procedures such as examination of the head, ear, nose, or throat for last.

Question 220

How many drinks does a person consume in 1 sitting for it to be considered binge drinking?

1. 3
2. 5
3. 7
4. 8

Answer 220

5

Question 221

Mental health problems associated with intimate partner violence include:

1. hallucinations
2. suicidality
3. schizophrenia
4. attention deficit/hyperactivity disorder

Answer 221

suicidality

Question 223

Which of the following best illustrates an abnormality of thought process?

1. Lability
2. Blocking
3. Compulsion
4. Aphasia

Answer 223

Blocking

Thought process is defined as the way a person thinks, or as the logical train of thought. Blocking is a sudden interruption in train of thought.

Question 224

an accurate understanding of the other person’s feeling =s within a communication context is an example of:

1. empathy
2. liking others
3. facilitation
4. a nonverbal listening technique

Answer 224

empathy

Question 226

While examining a broken arm of 4-year-old boy, select the appropriate assessment tool to evaluate his pain status:

1. 0-10 minute numeric rating scale
2. The wong-baker scale
3. simple descriptior scale
4. 0-5 numeric rating scale

Answer 226

The wong-baker scale

Question 227

Which BMI category in adults indicative of obesity?

1. 18.5-24.9
2. 25.0-29.9
3. 30.0-39.9
   4.

Answer 227

30.0-39.9

Question 228

The most appropriate introduction to use to start an interview with an older adult patient is:

1. “Mr. Jones, I want to ask you some questions about your health so that we can plan your care.”
2. “David, I am here to ask you questions about your illness; we want to determine what is wrong.”
3. “Mr. Jones, is it okay if I ask you several questions this morning about your health?”
4. “Because so many people have already asked you questions, I will just get the information from the chart.”

Answer 228

“Mr. Jones, I want to ask you some questions about your health so that we can plan your care.”

An older adult should be addressed by the last name; older adults may be offended by a younger person using their first names.

Question 229

While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following will most likely describe this patient’s view of wellness?

1. Good is hot.
2. Evil is hot.
3. The humors must be balanced.
4. The phlegm will be replaced with dryness.

Answer 229

The humors must be balanced.

The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the balance of the humors.Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not on their physical characteristics.The four humors of the body include the blood, phlegm, black bile, and yellow bile; the humors regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.

Question 230

A common physiologic change that occurs with pain is:

1. polyuria
2. hyperventiliation
3. hyperactive bowel sounds
4. tachycardia

Answer 230

tachycardia

Question 231

A complete data base is:

1. used to rapidly collect data and is often compiled concurrently with life-saving measures.
2. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system.
3. used to evaluate cause and etiology of disease.
4. used to perform a thorough or comprehensive health history and physical examination.

Answer 231

used to perform a thorough or comprehensive health history and physical examination.

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.

Question 232

the term “empacho” which is used to explain the Hispanic culture, can be explained as:

1. a folk healer who specializes in the use of herbs and tonic
2. an example of a culture-bound sydrome that has no equivalent from a biomedical/scientific perspective
3. a self-care complementary intervention
4. a regard for good behavior

Answer 232

an example of a culture-bound sydrome that has no equivalent from a biomedical/scientific perspective

Question 233

Marasmus is often characterized by:

1. severely depleted visceral proteins
2. elevated triglycerides
3. hyperglycemia
4. low weight for height

Answer 233

low weight for height

Question 234

Depending on the clinical situation, the nurse may establish one of four kinds of database. A focused database is decribed as:

1. including a complete health history and full physical examination
2. concerning mainly one problem
3. evaluation of a previously identified problem
4. rapid colection of data in conjunction with lifesaving measures

Answer 234

concerning mainly one problem

Question 235

Functional assessment measures how a person manages day-to-day activities. The impact of a disease on the daily acivities of older adults is referred to as:

1. interpersonal relationship assessment
2. instrumental activities of daily living
3. reason for seeking care
4. disease burden

Answer 235

disease burden

Question 236

At the end of the examination, the examiner should:

1. complete documentation before leaving the examination room.
2. have findings confirmed by another provider.
3. compare objective and subjective data for discrepancies.
4. review the findings with the patient.

Answer 236

review the findings with the patient.

At the end of the examination the examiner should summarize the findings and share necessary information with the patient.

Question 237

Elder abuse and neglect include:

1. Willful infliction of force
2. Witholding prescription medications
3. Not replacing broken eyeglasses
4. Threatening to place someone in a nursing home
5. All of the above

Answer 237

All of the above

Question 238

many of the traditional definitions of HEALTH tend to focus on:

1. beliefs of body and mind
2. equilibirum with others
3. physical, mental, and spiritual harmony
4. ability to perform activities daily living

Answer 238

physical, mental, and spiritual harmony