PCHA Final
A patient tells the nurse that he is very nervous, nauseated and that he "feels hot". This type of data
would be considered: - Answer-subjective
Because the physical environment in which an interview takes place is an important consideration for
the success of an interview, the interviewer should: - Answer-reduce noise by turning off televisions and
cell phones
A nurse is taking complete health histories on all the patients attending a wellness workshop. While
conducting an interview with a patient, the nurse asks, "Can you tell me a little about yourself?" This
question is an example of: - Answer-an open-ended question
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer
begins to discuss the child's treatment, however, the parent suddenly crosses the arms against the chest
and crosses the legs. Based on the understanding that nonverbal modes of communication provide clues
to understanding feelings, the sudden change in body position would suggest that the parent is: -
Answer-uncomfortable talking about his child's treatment
A 59-year-old patient is returning to the outpatient clinic for a follow up visit. The patient has a history
of ulcerative colitis. The patient states he has been having "black stools" for the last 24 hours. Which of
the following would be the most complete way for the nurse to document the patient's reason for
seeking care? - Answer-J.M. is a 59-year-old patient here for having "black stools" for the past 24 hours.
Which of the following statements best describes the purpose of a health history? - Answer-to provide a
database of subjective information about the patient's past and current health.
The inspection phase of the physical assessment: - Answer-begins the moment you first meet the person
and develop a "general survey".
,A patient is at the clinic for a physical examination. He states that he is "very anxious" about the physical
exam. What steps can the examiner take to make the patient more comfortable? - Answer-Appear
unhurried and confident when examining the patient.
When performing a physical examination, safety must be considered to protect the examiner and the
patient against the spread of infection. Which of the following statements describes the most
appropriate actions the examiner should take when performing a physical examination? - Answer-Wash
hands at the beginning of the examination and any time that one leaves and re-enters the room.
A 50-year-old patient who is taking anti-hypertensive medications returns to the clinic to have their
blood pressure (BP) checked. The last BP was 146/88. The BP reported to the nurse is 168/96. Both
blood pressures were taken at the brachial site. Which of the following is true regarding blood pressure
assessment in this patient? Choose all that apply:
1. The patient should be allowed to adequately rest prior to assessing the blood pressure.
2. The width of the cuff should cover 40% of the circumference of the upper arm.
3. The position of the arm used for blood pressure assessment should be above the level of the heart.
4. Goal blood pressure for this patient should be systolic less than 120 mm Hg and diastolic less than 80
mmHg.
5. The last audible sound auscultated during blood pressure assessment should be recorded for the
systolic reading.
6. An unsupported arm may be used for an accurate blood pressure measure - Answer-1, 2, 4
While caring for a patient with heart disease, the nurse notices an irregularity in the rhythm of the
patient's radial pulse. The previous assessment did not reveal an irregular pulse. What would be the
BEST action to take? - Answer-count the patient's apical pulse for one minute
Which of the following statements is true regarding use of the tympanic thermometer? - Answer-The
practitioner needs to wait at least 10 minutes to obtain the temperature if the patient has been
outdoors.
, Which of the following is true regarding an oral temperature? - Answer-The thermometer should be
placed in the posterior sublingual pocket of the mouth.
The nurse is taking a blood pressure on a patient; the patient's baseline blood pressure is unknown. The
nurse does not have any previous information about the patient's blood pressure measurements, nor is
the patient able to give any information about previous blood pressure readings. Which of the following
techniques would be the MOST accurate way to measure this patient's blood pressure? - Answer-Inflate
the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappeared.
A patient is being seen in the clinic for "fainting episodes". The patient has a blood pressure of 150/90 in
a lying position, 120/80 in a sitting position, and 90/60 in a standing position. How should the nurse
interpret these findings? - Answer-The change in blood pressure readings is called orthostatic
hypotension.
In the article by Rakotz, 'Medical students and measuring blood pressure: Results from the American
Medical Association Blood Pressure Check Challenge', what are the consequences of poor technique
when measuring blood pressure? - Answer-all of the above
- A 5- to 10-mm Hg error can result in an incorrect diagnosis of hypertension.
- Poor technique can cause patients with hypertension that is controlled to appear uncontrolled.
- Without accurate blood pressure readings, improving blood pressure control in unlikely because
physicians will not reliably know which patients need to be more aggressively treated and which do not.
Which of the following is correct about arterial blood pressure? - Answer-It is important to know the
normal blood pressure of each individual.
The nurse has just admitted the patient for evaluation of unexplained fever. The patient's temperature is
102o F, blood pressure 76/50 (baseline 130/74), pulse 110 bpm (baseline 72), respiration 16 bpm
(baseline 12). Which of the following best explains the patient's hypotension? - Answer-Vasodilation
secondary to his illness.
Which of the following is NOT true regarding assessment of the respiratory system? - Answer-Orthopnea
refers to a subjective feeling of not being able to get enough oxygen while standing.
A patient tells the nurse that he is very nervous, nauseated and that he "feels hot". This type of data
would be considered: - Answer-subjective
Because the physical environment in which an interview takes place is an important consideration for
the success of an interview, the interviewer should: - Answer-reduce noise by turning off televisions and
cell phones
A nurse is taking complete health histories on all the patients attending a wellness workshop. While
conducting an interview with a patient, the nurse asks, "Can you tell me a little about yourself?" This
question is an example of: - Answer-an open-ended question
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer
begins to discuss the child's treatment, however, the parent suddenly crosses the arms against the chest
and crosses the legs. Based on the understanding that nonverbal modes of communication provide clues
to understanding feelings, the sudden change in body position would suggest that the parent is: -
Answer-uncomfortable talking about his child's treatment
A 59-year-old patient is returning to the outpatient clinic for a follow up visit. The patient has a history
of ulcerative colitis. The patient states he has been having "black stools" for the last 24 hours. Which of
the following would be the most complete way for the nurse to document the patient's reason for
seeking care? - Answer-J.M. is a 59-year-old patient here for having "black stools" for the past 24 hours.
Which of the following statements best describes the purpose of a health history? - Answer-to provide a
database of subjective information about the patient's past and current health.
The inspection phase of the physical assessment: - Answer-begins the moment you first meet the person
and develop a "general survey".
,A patient is at the clinic for a physical examination. He states that he is "very anxious" about the physical
exam. What steps can the examiner take to make the patient more comfortable? - Answer-Appear
unhurried and confident when examining the patient.
When performing a physical examination, safety must be considered to protect the examiner and the
patient against the spread of infection. Which of the following statements describes the most
appropriate actions the examiner should take when performing a physical examination? - Answer-Wash
hands at the beginning of the examination and any time that one leaves and re-enters the room.
A 50-year-old patient who is taking anti-hypertensive medications returns to the clinic to have their
blood pressure (BP) checked. The last BP was 146/88. The BP reported to the nurse is 168/96. Both
blood pressures were taken at the brachial site. Which of the following is true regarding blood pressure
assessment in this patient? Choose all that apply:
1. The patient should be allowed to adequately rest prior to assessing the blood pressure.
2. The width of the cuff should cover 40% of the circumference of the upper arm.
3. The position of the arm used for blood pressure assessment should be above the level of the heart.
4. Goal blood pressure for this patient should be systolic less than 120 mm Hg and diastolic less than 80
mmHg.
5. The last audible sound auscultated during blood pressure assessment should be recorded for the
systolic reading.
6. An unsupported arm may be used for an accurate blood pressure measure - Answer-1, 2, 4
While caring for a patient with heart disease, the nurse notices an irregularity in the rhythm of the
patient's radial pulse. The previous assessment did not reveal an irregular pulse. What would be the
BEST action to take? - Answer-count the patient's apical pulse for one minute
Which of the following statements is true regarding use of the tympanic thermometer? - Answer-The
practitioner needs to wait at least 10 minutes to obtain the temperature if the patient has been
outdoors.
, Which of the following is true regarding an oral temperature? - Answer-The thermometer should be
placed in the posterior sublingual pocket of the mouth.
The nurse is taking a blood pressure on a patient; the patient's baseline blood pressure is unknown. The
nurse does not have any previous information about the patient's blood pressure measurements, nor is
the patient able to give any information about previous blood pressure readings. Which of the following
techniques would be the MOST accurate way to measure this patient's blood pressure? - Answer-Inflate
the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappeared.
A patient is being seen in the clinic for "fainting episodes". The patient has a blood pressure of 150/90 in
a lying position, 120/80 in a sitting position, and 90/60 in a standing position. How should the nurse
interpret these findings? - Answer-The change in blood pressure readings is called orthostatic
hypotension.
In the article by Rakotz, 'Medical students and measuring blood pressure: Results from the American
Medical Association Blood Pressure Check Challenge', what are the consequences of poor technique
when measuring blood pressure? - Answer-all of the above
- A 5- to 10-mm Hg error can result in an incorrect diagnosis of hypertension.
- Poor technique can cause patients with hypertension that is controlled to appear uncontrolled.
- Without accurate blood pressure readings, improving blood pressure control in unlikely because
physicians will not reliably know which patients need to be more aggressively treated and which do not.
Which of the following is correct about arterial blood pressure? - Answer-It is important to know the
normal blood pressure of each individual.
The nurse has just admitted the patient for evaluation of unexplained fever. The patient's temperature is
102o F, blood pressure 76/50 (baseline 130/74), pulse 110 bpm (baseline 72), respiration 16 bpm
(baseline 12). Which of the following best explains the patient's hypotension? - Answer-Vasodilation
secondary to his illness.
Which of the following is NOT true regarding assessment of the respiratory system? - Answer-Orthopnea
refers to a subjective feeling of not being able to get enough oxygen while standing.
