TEST QUESTIONS AND DETAILED PATIENT
CARE SCENARIOS AND NURSING
INTERVENTIONS BREAKDOWN FULL REVIEW
◉ Which of the following is included in documenting a history
source?
a. Appearance, dress, and hygiene
b. Documented relationship of support systems
c. Reliability of informant
d. Cognition and literacy level. Answer: c
◉ 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
a. the patient's perception of pain.
b. the nature or character of the headache.
c. relieving factors.
d. aggravating factors.. Answer: d
◉ The CAGE test is a screening questionnaire that helps to identify
,a. depression.
b. excessive or uncontrollable c. drinking.
c. unhealthy lifestyle behaviors.
d. personal response to stress.. Answer: b
◉ The "review of systems" in the health history is
a. a short statement of general health status.
b. an evaluation of past and present health state of each body
system.
c. a documentation of the problem as perceived by the patient.
d. a record of objective findings.. Answer: b
◉ When recording information for the review of systems, the
interviewer must document
a. "negative" under the system heading.
b. the presence or absence of all symptoms under the system
heading.
c. objective data that support the history of present illness.
d. physical findings, such as skin appearance, to support historic
data.. Answer: b
, ◉ Assessment of self-esteem and self-concept is part of the
functional assessment. Areas covered under self-esteem and self-
concept include
a. education, financial status, and value-belief system.
b. family role, interpersonal relations, social support, and time spent
alone.
c. stressors, coping mechanisms, and change in past year.
d. exercise and activity, leisure activities, and level of independence..
Answer: a
◉ PQRSTU is a mnemonic that helps the clinician to remember to
address characteristics specific to
a. the ability to perform activities of daily living (ADLs).
b. substance use and abuse.
c. pain presentation.
d. severity of dementia.. Answer: c
◉ 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
a. ask the patient if there is someone who could verify information.
b. rephrase the same questions later in the interview.
c. call a family member to confirm information.
d. review previous medical records.. Answer: b