Nurs 125 Questions With Complete Solutions
1. A patient on a medical-surgical floor reports having shortness of breath.
The nurse needs to conduct which type of assessment?: A problem-based/focused
assessment.
-This type of assessment is limited to a specific problem or complaint
2. For which patient is a shift-assessment indicated?: ***The person who has
abdominal surgery yesterday
The person who is c/o chest pain
The person being admitted to long-term care
The person who is at a health fair
-The nurse would need to do a shift assessment on a surgical patient.
3. Which of the following examples represents a secondary prevention level
of health promotion?: Immunizations
Exercise
Hypertension management
***Blood pressure screenings
,-Secondary prevention consists of screening efforts to promote early detection of disease like blood pressure,
mammogram and colorectal screenings.
4. Which of the following is an example of objective data?: Headache
***Vomiting
Joint Pain
Nausea
-Vomiting can be observed, smelled, and measured
5. A nurse suspects a patient is a victim of physical abuse. Which response by
the nurse will most likely encourage the patient to confide in the nurse?: "If
someone hit you, you can get a restraining order"
*** "I've seen people who have been hurt by their significant others. Do you feel safe in your home?"
"You've got a huge bruise on your face. Who hit you?"
"That bruise looks tender. I don't know how people can do that to one another."
-This question is an acceptable screening question when domestic violence is suspected. p. 16
6. A patient answers questionably quietly and appears sad. While answering the
questions about her marriage, she begins to cry. Which response by the nurse
,is appropriate in this situation?: ***"I see that you are upset. Is there something you'd like to
discuss?" "Everyone has ups and downs in their marriage. What problems are you having?"
"Don't cry! I'll come back when you've settled down."
"I only have a few more questions to ask and then I'll leave you alone for awhile."
-This is a therapeutic response. p. 12
7. A nurse is interviewing a patient. Which of the following questions is
an open-ended question?: Can you tell me how you have been feeling?
-This is an open-ended question. The patient would need to answer more than a "yes" or "no" to this question. p. 11
8. When interviewing a patient to obtain a health history, asking if the
patient has "dyspnea" can fall in which of the following systems?: Respiratory and
Cardiovascular
-Dyspnea (difficulty breathing) falls under both respiratory and cardiovascular. p. 18
9. A nurse asks a patient to rate their pain on a scale of 0-10. This is which
part of the mnemonic for symptom analysis of "OLD CARTS": Severity
, -Using a rating scale helps describe the severity of the symptom p. 15
10. When examining a patient, the nurse remembers to follow which
principle of Standard Precautions?: Wear gloves when in contact with the patient's blood or
other body fluids.
-Always wear gloves when you are in contact with patient's blood or other body fluids. p. 22
11. Which of the following is a correct statement regarding the
technique of LIGHT palpation. Light palpation is:: used to determine organ size
***used to assess tenderness
performed by pressing down on a patient's body to a depth of 4 cm
performed only using the fingertips
-light palpation is used to assess skin, pulses, and tenderness. P. 24
12. The nurse is unable to hear the patient's breath sounds. To determine the
cause of this problem, the nurse needs to ensure that the:: valve is open to the
diaphragm
on the head of the stethoscope.
-The valve needs to be open to the diaphragm. If it is not open to the diaphragm, then it is open to the bel. The
1. A patient on a medical-surgical floor reports having shortness of breath.
The nurse needs to conduct which type of assessment?: A problem-based/focused
assessment.
-This type of assessment is limited to a specific problem or complaint
2. For which patient is a shift-assessment indicated?: ***The person who has
abdominal surgery yesterday
The person who is c/o chest pain
The person being admitted to long-term care
The person who is at a health fair
-The nurse would need to do a shift assessment on a surgical patient.
3. Which of the following examples represents a secondary prevention level
of health promotion?: Immunizations
Exercise
Hypertension management
***Blood pressure screenings
,-Secondary prevention consists of screening efforts to promote early detection of disease like blood pressure,
mammogram and colorectal screenings.
4. Which of the following is an example of objective data?: Headache
***Vomiting
Joint Pain
Nausea
-Vomiting can be observed, smelled, and measured
5. A nurse suspects a patient is a victim of physical abuse. Which response by
the nurse will most likely encourage the patient to confide in the nurse?: "If
someone hit you, you can get a restraining order"
*** "I've seen people who have been hurt by their significant others. Do you feel safe in your home?"
"You've got a huge bruise on your face. Who hit you?"
"That bruise looks tender. I don't know how people can do that to one another."
-This question is an acceptable screening question when domestic violence is suspected. p. 16
6. A patient answers questionably quietly and appears sad. While answering the
questions about her marriage, she begins to cry. Which response by the nurse
,is appropriate in this situation?: ***"I see that you are upset. Is there something you'd like to
discuss?" "Everyone has ups and downs in their marriage. What problems are you having?"
"Don't cry! I'll come back when you've settled down."
"I only have a few more questions to ask and then I'll leave you alone for awhile."
-This is a therapeutic response. p. 12
7. A nurse is interviewing a patient. Which of the following questions is
an open-ended question?: Can you tell me how you have been feeling?
-This is an open-ended question. The patient would need to answer more than a "yes" or "no" to this question. p. 11
8. When interviewing a patient to obtain a health history, asking if the
patient has "dyspnea" can fall in which of the following systems?: Respiratory and
Cardiovascular
-Dyspnea (difficulty breathing) falls under both respiratory and cardiovascular. p. 18
9. A nurse asks a patient to rate their pain on a scale of 0-10. This is which
part of the mnemonic for symptom analysis of "OLD CARTS": Severity
, -Using a rating scale helps describe the severity of the symptom p. 15
10. When examining a patient, the nurse remembers to follow which
principle of Standard Precautions?: Wear gloves when in contact with the patient's blood or
other body fluids.
-Always wear gloves when you are in contact with patient's blood or other body fluids. p. 22
11. Which of the following is a correct statement regarding the
technique of LIGHT palpation. Light palpation is:: used to determine organ size
***used to assess tenderness
performed by pressing down on a patient's body to a depth of 4 cm
performed only using the fingertips
-light palpation is used to assess skin, pulses, and tenderness. P. 24
12. The nurse is unable to hear the patient's breath sounds. To determine the
cause of this problem, the nurse needs to ensure that the:: valve is open to the
diaphragm
on the head of the stethoscope.
-The valve needs to be open to the diaphragm. If it is not open to the diaphragm, then it is open to the bel. The
