Health Assessment Exam 2 Test Bank Questions
1. The nurse is preparing to assess the remote memory of a client who has a
diagnosis of early stage Alzheimer's disease. Which question would be most
appropriate for the nurse to use?
A) Can you tell me what you have eaten in the last 24 hours?
B) When did you get your first job?
C) What did you do last evening?
D) How are an apple and orange the same?: B) When did you get your first job?
2. When assessing the mental status of a 67-year-old woman, the nurse detects
some difficulty with free-flow of thought and the woman's ability to follow
directions. Which of the following would the nurse do first?
A) Use a geriatric depression scale
B) Refer for further medical evaluation
C) Assess the client's vision and hearing
D) Refer the client to social services for home assistance: C) Assess the client's vision and
hearing
3. The nurse utilizes the Depression Questionnaire on a client who has recently
moved to a long-term care facility. The total score is 22. Which of the following
would be most appropriate for the nurse to do next?
A) Refer for further evaluation
B) Evaluate benefits vs risks of a mental health label
C) Assess further for dementia
D) Document this as a normal score: A) Refer for further evaluation
4. The nurse notes that an older adult client is wearing multiple layers of
clothing on a warm fall day. Which of the following would be the nurse's
priority assessment at this time?
A) Asking whether the client often feels cold
,B) Assessing the client's developmental level
C) Reviewing the client's culture for possible influence
D) Observing the client's overall hygiene: A) Asking whether the client often feels cold
5. A nurse is working in a clinic in a low-income neighborhood and assesses as
female adult client who states that she has a urinary tract infection. The nurse
notes that the client is unkempt, wearing stained clothing, and has a strong
body odor. The client mentions that she was evicted from her apartment two
weeks ago. Which nursing diagnosis would the nurse most likely identify for
this client?
A) Caregiver role stain related to fatigue
B) Impaired skin integrity related to neurologic deficits
C) Deficit fluid volume related to possible urinary tract infection
D) Self-care deficit related to possible homelessness: D) Self-care deficit related to
possible homelessness
6. When preparing to obtain information about a client's mental and
psychosocial status, which of the following would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and behaviors
B) Perform a neurologic examination to determine any deficits
C) Check the client's level of consciousness for changes
D) Explain the purpose of the exam and types of questions: D) Explain the purpose of the
exam and types of questions
7. A nursing student has been assigned to the care of a client whose history
suggests the need for mental status assessment. This client most likely has a
history of health problems affecting what body system?
A) Respiratory
B) Neurologic
C) Cardiovascular
D) Renal: B) Neurologic
, Health Assessment Exam 2 Test Bank Questions
8. The nurse begins the physical examination of newly admitted client by
assessing the client's mental status. What is the nurse's best rationale for
performing the mental status exam early in the assessment?
A) The client will be less anxious early, providing the nurse with more accurate and
reliable data
B) The exam can provide clues about the validity of the client's responses now and
throughout
C) The exam provides data about mental health problems that the client may be afraid
to report
D) The client's fears about having a serious illness may be alleviated by the results of
the exam: B) The exam can provide clues about the validity of the client's responses now
and throughout
9. A client's recent episode of becoming lost near his home has prompted the
nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool.
The nurse should begin this assessment by asking what question?
A) How would you respond if someone said that you might have dementia?
B)Can I ask you some questions about your memory?
C) Do you generally consider yourself to be an intelligent person?
D) I want to ask you some questions to see if you have Alzheimer's: B) Can I ask you some
questions about your memory?
10. Assessment of a client who has suffered a recent stroke reveals that he is
unresponsive to all stimuli and his eyes remain closed. The nurse documents
the clients level of consciousness as which of the following?
A) Obtunded
B) Stupor
C) Coma
D) Lethargy: C) Coma
, 11. An emergency department nurse has utilized the Confusion Assessment
Method (CAM) in the assessment of a 79 year old client with a new onset of
urinary incontinence. This assessment tool will allow the nurse to confirm the
presence of what health problem?
A) Delirium
B) Vascular dementia
C) Schizophrenia
D) Psychosis: A) Delirium
12. The nurse is assessing a client using the Glasgow Coma Scale following an
acute hypoglycemic episode and obtains a score of 14. The nurse interprets
this as indicating which of the following?
A) Deep coma
B) Coma
C) Obtunded
D) Alert and oriented: D) Alert and oriented
13. A woman brings her 69 year old husband to the clinic for an evaluation
because he has become increasingly forgetful. Which of the following would
lea the nurse to suspect that the client has Alzheimer's disease? Select all that
apply
A) He repeats the same story, word for word, over and over again
B) He took a fall when he was replacing a lightbulb last month
C) I have to balance the checkbook now because he just won't do it
D) If I don't tell him when to shower, he won't and will fight me on it
E) He got lost lasting to the pharmacy around the corning the other day: A) He repeats
the same story, word for word, over and over again
C) I have to balance the checkbook now because he just won't do it
D)If I don't tell him when to shower, he won't and will fight me on it
E) He got lost lasting to the pharmacy around the corning the other day
1. The nurse is preparing to assess the remote memory of a client who has a
diagnosis of early stage Alzheimer's disease. Which question would be most
appropriate for the nurse to use?
A) Can you tell me what you have eaten in the last 24 hours?
B) When did you get your first job?
C) What did you do last evening?
D) How are an apple and orange the same?: B) When did you get your first job?
2. When assessing the mental status of a 67-year-old woman, the nurse detects
some difficulty with free-flow of thought and the woman's ability to follow
directions. Which of the following would the nurse do first?
A) Use a geriatric depression scale
B) Refer for further medical evaluation
C) Assess the client's vision and hearing
D) Refer the client to social services for home assistance: C) Assess the client's vision and
hearing
3. The nurse utilizes the Depression Questionnaire on a client who has recently
moved to a long-term care facility. The total score is 22. Which of the following
would be most appropriate for the nurse to do next?
A) Refer for further evaluation
B) Evaluate benefits vs risks of a mental health label
C) Assess further for dementia
D) Document this as a normal score: A) Refer for further evaluation
4. The nurse notes that an older adult client is wearing multiple layers of
clothing on a warm fall day. Which of the following would be the nurse's
priority assessment at this time?
A) Asking whether the client often feels cold
,B) Assessing the client's developmental level
C) Reviewing the client's culture for possible influence
D) Observing the client's overall hygiene: A) Asking whether the client often feels cold
5. A nurse is working in a clinic in a low-income neighborhood and assesses as
female adult client who states that she has a urinary tract infection. The nurse
notes that the client is unkempt, wearing stained clothing, and has a strong
body odor. The client mentions that she was evicted from her apartment two
weeks ago. Which nursing diagnosis would the nurse most likely identify for
this client?
A) Caregiver role stain related to fatigue
B) Impaired skin integrity related to neurologic deficits
C) Deficit fluid volume related to possible urinary tract infection
D) Self-care deficit related to possible homelessness: D) Self-care deficit related to
possible homelessness
6. When preparing to obtain information about a client's mental and
psychosocial status, which of the following would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and behaviors
B) Perform a neurologic examination to determine any deficits
C) Check the client's level of consciousness for changes
D) Explain the purpose of the exam and types of questions: D) Explain the purpose of the
exam and types of questions
7. A nursing student has been assigned to the care of a client whose history
suggests the need for mental status assessment. This client most likely has a
history of health problems affecting what body system?
A) Respiratory
B) Neurologic
C) Cardiovascular
D) Renal: B) Neurologic
, Health Assessment Exam 2 Test Bank Questions
8. The nurse begins the physical examination of newly admitted client by
assessing the client's mental status. What is the nurse's best rationale for
performing the mental status exam early in the assessment?
A) The client will be less anxious early, providing the nurse with more accurate and
reliable data
B) The exam can provide clues about the validity of the client's responses now and
throughout
C) The exam provides data about mental health problems that the client may be afraid
to report
D) The client's fears about having a serious illness may be alleviated by the results of
the exam: B) The exam can provide clues about the validity of the client's responses now
and throughout
9. A client's recent episode of becoming lost near his home has prompted the
nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool.
The nurse should begin this assessment by asking what question?
A) How would you respond if someone said that you might have dementia?
B)Can I ask you some questions about your memory?
C) Do you generally consider yourself to be an intelligent person?
D) I want to ask you some questions to see if you have Alzheimer's: B) Can I ask you some
questions about your memory?
10. Assessment of a client who has suffered a recent stroke reveals that he is
unresponsive to all stimuli and his eyes remain closed. The nurse documents
the clients level of consciousness as which of the following?
A) Obtunded
B) Stupor
C) Coma
D) Lethargy: C) Coma
, 11. An emergency department nurse has utilized the Confusion Assessment
Method (CAM) in the assessment of a 79 year old client with a new onset of
urinary incontinence. This assessment tool will allow the nurse to confirm the
presence of what health problem?
A) Delirium
B) Vascular dementia
C) Schizophrenia
D) Psychosis: A) Delirium
12. The nurse is assessing a client using the Glasgow Coma Scale following an
acute hypoglycemic episode and obtains a score of 14. The nurse interprets
this as indicating which of the following?
A) Deep coma
B) Coma
C) Obtunded
D) Alert and oriented: D) Alert and oriented
13. A woman brings her 69 year old husband to the clinic for an evaluation
because he has become increasingly forgetful. Which of the following would
lea the nurse to suspect that the client has Alzheimer's disease? Select all that
apply
A) He repeats the same story, word for word, over and over again
B) He took a fall when he was replacing a lightbulb last month
C) I have to balance the checkbook now because he just won't do it
D) If I don't tell him when to shower, he won't and will fight me on it
E) He got lost lasting to the pharmacy around the corning the other day: A) He repeats
the same story, word for word, over and over again
C) I have to balance the checkbook now because he just won't do it
D)If I don't tell him when to shower, he won't and will fight me on it
E) He got lost lasting to the pharmacy around the corning the other day
