NSG 3009/ NSG3009 Exam 1 (NEW 2025/2026 Update) Principles of Assessment | Verified Questions & Answers | 100% Correct Solutions | Grade A – South University

NSG 3009/ NSG3009 Exam 1 (NEW 2026/2027 Update) Principles of Assessment | Verified Questions & Answers | 100% Correct Solutions | Grade A – South University Q. Title VI of the Civil Rights Act of 1964 ANSWER provides people with limited English proficiency access to health care; these individuals cannot be denied health care services. Q. Limited English proficiency is associated with ANSWER a lower quality of care Q. English proficiency is associated with ANSWER a higher quality of care. Q. Patients with language barriers have an increased risk of ANSWER nonadherence to medication regimens Q. What is the yin/yang theory of health? ANSWER Health exists when all aspects of the person are in perfect balance. Q. hot/cold theory ANSWER health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person Q. biomedical model of Western tradition views health as ANSWER the absence of disease. Q. biomedical or scientific theory ANSWER high-level wellness (or health) exists with optimal functioning of the human body. Q. Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? ANSWER Heritage consistency Q. Behavior theory or behaviorism ANSWER learning theory Q. Carl Rogers described the concepts of congruence and incongruence as ANSWER important ideas in his theory of personality and human development. Q. Socialization ANSWER the process of being raised within a culture and acquiring the characteristics of that group. Q. Which of the following symptoms is greatly influenced by a person's cultural heritage? ANSWER Pain Q. Hearing loss is more common in ANSWER whites than blacks Q. lactose intolerance is common in ANSWER African Americans, American Indians, and Asian Americans. Q. When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.) ANSWER -his or her own heritage. - the heritage of the nursing profession. - the heritage of the patient. -the heritage of the health care system Q. When preparing the physical setting for an interview, the interviewer should: ANSWER conduct the interview at eye level and at a distance of 4 to 5 ft. Q. 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. ANSWER 7 Q. Which of the following statements made by the interviewer would be an appropriate response? ANSWER "tell me what yu mean by 'bad blood.'" Q. False reassurance example ANSWER "I know just hw you feel" Q. 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: ANSWER Helps the pt understand personal feelings in relation to his or her verbal message Q. The use of euphemisms to avoid reality or to hide feelings is known as: ANSWER avoidance language Q. empathy ANSWER viewing the world from the other person's inner frame of reference... Q. When addressing a toddler during the interview, the health care provider should: ANSWER use short, simple, concrete sentences Q. detailed explanations would be appropriate for which age? ANSWER school-aged child, adolescent, adult Q. Nonverbal communication is the primary form of communication for which group of individuals? ANSWER infants Q. preschoolers' communication is ANSWER direct, concrete, literal, and set in the present Q. adolescents should be ANSWER treated wit respect; the nurse should use open, honest professional communication. Q. older adults may need ANSWER special considerations related to physical limitations Q. Viewing the world from another person's inner frame of reference is called: ANSWER empathy Q. Reflection is ANSWER repeating part of what the person has just said Q. Clarification is ANSWER used to summarize the person's words or to simplify the words to make them clearer.. Q. sympathy ANSWER is a social affinity in which one person stands with another person, closely understand his/her feelings Q. An example of an open-ended question or statement is: ANSWER "tell me about your pain" Q. short ended question ANSWER "On a scale of 1 to 10, how would you rate your pain?"; "I can see that you are quite uncomfortable"; and "You are upset about the level of pain, right?" are closed or direct questions. Q. The most appropriate introduction to use to start an interview with an older adult patient is ANSWER "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." Q. closed ended question example for older adult ANSWER "Mr.JONes, is it okay if I ask you several questions this morning about your health?" Q. Which of the following is included in documenting a history source? ANSWER Reliably of informant Q. source of history is ANSWER a record of who furnishes the information, how reliable the informant seems and how willing he or she is to communicate.. there should be a note of any special circumstances...(use of an interpreter) Q. Appearance, dress and hygiene are observations included in what survey ANSWER general interpersonal relationships and resources such as support systems are assessed during what part of the asessment functional 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: aggravating factors Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help. The CAGE test is a screening questionnaire that helps to identify: excessive or uncontrollable drinking. Correct CAGE stands for C-cut down A-annoyed G-guilty E-eye opener The health history asses what? lifestyle (exercise, diet, risk reduction) and health promotion behaviors Coping and stress management are assessed during the functional assessment of the complete health history Depression is assessed during the review of systems and during the mental status assessment (mood and affect).. what short form is used to asses older adults for depression? Geriatric depression scale The "review of systems" in the health history is: an evaluation of past and present health state of each body system what is the purpose of the "review of systems" 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. Objective data are the observations obtained by the health care professional during the physical examination When recording information for the review of systems, the interviewer must document: the presence or absence of all symptoms under the system heading. Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include: education, financial status, and value-belief system. PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to pain presentation. what does PQRSTU stand for? pain symptoms P-provocative or palliative Q-quality or quantity R- region or radiation S-severity scale T-timing U-understnad pt perception test used to assess for dementia mini-manta state exam the set test the short portable mental status questionnaire the mini-cog the blessed orientation-memory -concentraion test 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: rephrase the same questions later in the interview. When taking a health history from an adolescent, the interviewer should: interview the youth alone with a parent in the waiting area what method of interviewing is best with adolescents? The HEEADSSS method of interviewing adolescents has essential questions, important questions, and situational questions What information is included in greater detail when taking a health history on an infant? Nutritional data A full mental status examination should be completed if the patient: has a change in behavior and the family is concerned. family members concerned about a person's behavioral changes; brain lesions; aphasia; or symptoms of psychiatric mental illness, especially with acute onset. Aphasia is best described as: a language disturbance in speaking, writing, or understanding Apraxia an impaired ability to carry out motor activities despite intact motor function. Agnosia an impaired ability to identify objects correctly despite intact sensory function. Dementia the development of multiple cognitive deficits with both memory impairment and a cognitive disturbance A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's: judgement Thought processes should be consistent, coherent, relevant, and logical Perceptions should be congruent; the person should be consistently aware of reality. Intellectual functioning is measured by problem-solving and reasoning abilities A major characteristic of dementia is: impaired short term and long term memory hallucinations are a form of what? delirium delirium is a disturbance that develops over a short period of time & may be substance-induced. Mental status assessment documents emotional and cognitive functioning 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: appearance, behavior, cognition, and thought processes. an older adult.. has a slower response time Which of the following statements about mental status testing of children is correct? Abnormal findings are usually related to not achieving an expected developmental milestone. Which of the following best illustrates an abnormality of thought process? blocking Lability an abnormality of mood and affect; the person has a rapid shift of emotions. compulsion an abnormality of thought content; the person displays unwanted repetitive, purposeful acts. The mental status examination: assesses mental health strengths and coping skills and screens for any dysfunction. The nurse would expect an older adult to have higher blood alcohol levels because older adults have: decreased liver metabolism and kidney functioning aging adults have lose of muscle mass 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: relationship trouble with family or friends. alcohol abuse crittera 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). If the patient has a drinking problem, which statement by the nurse is most appropriate? I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help." 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? Elevated gamma-glutamyl transferase (GGT) AST less sensitive biochemical marker MCV less sensitive biochemical marker BAC an indicator of alcohol consumption but does not provide information to validate chronic alcohol use. A patient with chronic alcohol use is most at risk for developing which of the following cardiovascular diseases? hypertension Subjective data: What the person says about himself or herself during history taking objective data: what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination Data base: Formed from objective/subjective data and the s record and lab studies Assessment: The collection of data about an individual's health state Diagnostic reasoning: the process of analyzing health data and drawing conclusions to identify diagnoses After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: Objective A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: Subjective The patient's record, laboratory studies, objective data, ande data combine to form the Data base When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: Validate the data by asking a coworker to listen to the breath sounds. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: A set of rules Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: intuition The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? EBP emphasizes the use of best evidence with the clinicians experience. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? Individual with shortness of breath and respiratory distress When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? Abnormal lab values Which critical thinking skill helps the nurse see relationships among the data? Clustering related cues The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. nursing The nursing process is a sequential method of problem-solving that nurses use and includes which steps? Assessment, diagnosis, outcome identification, planning, implementation, and evaluation A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? Breathing, pain, and sleep Which of these would be formulated by a nurse using diagnostic reasoning? diagnostic hypothesis Barriers to incorporating EBP include: Nurses lack of research skills in evaluating quality of research studies What step of the nursing process includes data collection by health history, physical examination, and interview? assessment During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? Teach the nurses how to conduct electronic searches for research studies. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? Holistic health views the mind, body, and spirit as interdependent. The nurse recognizes that the concept of prevention in describing health is essential because: Prevention places the emphasis on the link between health and personal behavior. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: 2 5 cm scar on the right lower forearm. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? A complete health data base because of the nurses primary responsibility for monitoring the patients health Which situation is most appropriate during which the nurse performs a focused or problem-centered history? patient in outpatient clinic has cold/flu like symptoms A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: Collect a follow-up data base and then check her blood pressure. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? Simultaneously ask history questions while performing the examination and initiating life-saving measures. The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: Learned through language acquisition and socialization. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? Culture adapts to specific environmental factors and available natural resources. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? culture When discussing the use of the term subculture, the nurse recognizes that it is best described as: Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: Hispanic During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? Ask the patient about the item and its significance. The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: Understands and attends to the total context of the patients situation. The nurse recognizes that an example of a person who is heritage consistent would be a: Woman who follows the traditions that her mother followed regarding meals. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? Ethnicity pertains to a social group within the social system that claims shared values and traditions. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? Personal effort made to find purpose and meaning in life A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? Assimilation The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? Do you mostly participate in the religious traditions of your family? In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: Consider these symptoms part of normal living, not symptoms of ill health. The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? Biomedical An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with: foods that are hot or yang The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: exhibiting verbal and nonverbal behaviors that do not match Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? Man whose wife has just been diagnosed with lung cancer The nurse makes which adjustment in the physical environment to promote the success of an interview? Reduces noise by turning off televisions and radios In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? Note-taking may impede the nurses observation of the patients nonverbal behaviors. The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. opening or intro A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened. During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? open-ended A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain? In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: confrontation When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? Be silent, and allow him to continue when he is ready. A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: what do you mean by fits? A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? It must be so hard to face this all alone. The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: Allow time for the patient to confirm or correct the inference. During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: It sounds as if you might be afraid of how your husband will respond. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? To provide a database of subjective information about the patients past and current health When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: Provided consistent information and therefore is reliable. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response? Can you point to where it hurts? When performing a physical assessment, the first technique the nurse will always use is: inspection The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: Takes time and reveals a surprising amount of information. The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? Dorsal surface of the hand; the skin is thinner on this surface than on the palms. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? palpation The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed? The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. The nurse would use bimanual palpation technique in which situation? Palpating the kidneys and uterus The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue. Density The nurse is performing a general survey. Which action is a component of the general survey? Observing the patients body stature and nutritional status A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? Prehypertension When measuring a patients weight, the nurse is aware of which of these guidelines? Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. During an examination of a child, the nurse considers that physical growth is the best index of a childs: general health The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? Presence of kyphosis and flexion in the knees and hips 7. The nurse should measure rectal temperatures in which of these patients? comatose adult 11. The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? radiation When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature? The body temperature of the older adult is lower than that of a younger adult. 18. To assess a rectal temperature accurately in an adult, the nurse would: Use a lubricated blunt tip thermometer. The pulse is counted for: 1 minute if irregular 20. When assessing a patients pulse, the nurse should also notice which of these characteristics? force 1. When evaluating a patients pain, the nurse knows that an example of acute pain would be: low back pain 9. When assessing the quality of a patients pain, the nurse should ask which question? what does your pain feel like? 11. The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? perception 12. When assessing the intensity of a patients pain, which question by the nurse is appropriate? how much pain do you have now?