NR302 / NR 302 Exam 1 (New 2026/2027 Update) Health Assessment I |Review with Questions and Answers| 100% Correct | A Grade -Chamberlain

NR302 / NR 302 Exam 1 (New 2026/2027 Update) Health Assessment I |Review with Questions and Answers| 100% Correct | A Grade -Chamberlain Q. What is subjective information? ANSWER What you assess What the patient tells you Lab results Vital signs What the patient tells you Q. What is objective information? ANSWER What we assess What the patient states Complaints of nausea Complaints of dizziness What we assess Q. In the nursing process, the diagnosis phase includes what actions? Select all that apply. ANSWER Cluster data together Make inferences Collect data Prioritize goals Cluster data together Make inferences Q. Open-ended questions should be used during what part of the patient interview? ANSWER The introduction The closure When trying to find out specific information When trying to find out detailed information The introduction Q. Closed-ended questions are used to obtain detailed and specific answers. ANSWER True False True Q. How can the communication method of confrontation be used in a patient interview? ANSWER To inform the patient To condense facts To link events To clarify inconsistent information To clarify inconsistent information Q. A patient who comes to the ER with an altered level of consciousness should be seen before an asthma attack patient. ANSWER True False False Q. Any person who can speak the patient's language is allowed to interpret. ANSWER True False False Q. What makes a first level priority so important? ANSWER It's not, a third level is It is causing the patient pain It is emergent and life-threatening The patient will not follow direction It is emergent and life-threatening Q. The diaphragm of the stethoscope is used for low-pitched sounds. ANSWER True False False Q. The planning phase of the nursing process involves what action? ANSWER Establish priorities Interpret data Collect data Evaluate progress Establish priorities Q. When implementing a plan of care, the nurse only relies on themselves to complete it. ANSWER True False False Q. What characterizes a lethargic level of consciousness? ANSWER The person is awake and alert. Constant stimulation is required to keep the patient awake. A person will wake when stimulated but goes back to sleep. The person does not wake up. A person will wake when stimulated but goes back to sleep. Q. What could be actions of a person experiencing delirium? Select all that apply. ANSWER Disruptive behavior Disorganized behavior Very sleepy Calm and cooperative Disruptive behavior Disorganized behavior Q. Place the database types in order from most comprehensive to least." ANSWER Emergent Complete Follow-up Focused or Problem-centered Complete Focused or Problem-centered Follow-up Emergent Q. The order of the physical assessment is inspect, palpate, auscultate, and then percuss. ANSWER True False False Q. What are the qualities we assess when palpating a pulse? ANSWER Rate, Rhythm, & Force Rate & Force Rhythm & Rate Force & Rhythm Rate, Rhythm, & Force Q. Acute pain is different than neuropathic pain how? ANSWER It remains for longer than 6 months. It involves damaged nerve pathways. It is self-limiting and goes away. It is difficult to treat. It is self-limiting and goes away. Q. BMI stands for Body Mass Index. ANSWER True False True Q. What kind of physical complaints can affect a patient's nutritional status? ANSWER Impaired vision Nausea & vomiting Impaired hearing Impaired balance Nausea & vomiting Q. Referred pain can be described as: ANSWER Pain felt long after an injury occurs. Pain felt in an area that is different than where the injury/trauma occurs. Pain from an injury to the skin. Pain from an injury to a ligament or joint. Pain felt in an area that is different than where the injury/trauma occurs. Q. The patient is the most reliable source to report pain. ANSWER True False True Q. The nine categories that must be included in a complete health history include: Select all that apply. ANSWER SBAR Medication reconciliation Biographical data Review of systems Medication reconciliation Biographical data Review of systems Q. How do you stay safe while in an aggressive patient's room? ANSWER Close the door securely behind you when entering. Make sure you are close to the patient when talking. Keep the door open. Position yourself in the corner of the room, farthest from the door. Keep the door open. A patient who knows their name and situation (or purpose), is said to be alert & oriented x what?" Two One Four Three Two How should adolescents be approached during an interview? Quickly Respectfully With authority Ignoring them at first Respectfully The older a patient is the more confused they are. True False False When communicating with an adolescent, we should remember to: Select all that apply. Remain calm Maintain eye contact Use closed-ended questions to keep answers short Establish trust Remain calm Maintain eye contact Establish trust During the diagnosis stage of the nursing process we identify interventions and set timelines. True False False What is the most important thing we can do to prevent the spread of infection? Use alcohol-based cleaners only. Wear gloves. Wash our hands! Wash our hands! Cultural awareness is critical in nursing. Who is the best person to ask about beliefs? The family The patient Review the chart Just guess The patient In the acronym SBAR, the background includes providing specific information relative to the patient issue. True False False A. S., a 35-year-old, is at your clinic today for a well visit. She recently moved to the area and is establishing with a new primary care provider. What information would you include in the database for this new patient? Select all that apply. a. Current health state b. Lifestyle and risk factors c. Only subjective information d. Only objective information e. Physical examination f. Health maintenance behaviors g. Your perception of the patient's health h. The patient's perception of current health a. Current health state b. Lifestyle and risk factors e. Physical examination f. Health maintenance behaviors h. The patient's perception of current health You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply. a. Normal skin turgor b. Normal S1, S2 heart sounds c. Pale skin d. Tachypnea (rapid breathing) e. Tachycardia (rapid pulse) f. Clear breath sounds c. Pale skin d. Tachypnea (rapid breathing) e. Tachycardia (rapid pulse) You are working in the emergency department and receive a patient who was admitted via ambulance. The patient is alert, but the injuries are severe. What are your priorities when collecting this patient's emergency database? a. A complete health history and full physical examination b. A full list of medications, allergies, family history, and personal history c. Previously identified problems including any current treatments and health promotion d. Collect critical information as you begin lifesaving measures d. Collect critical information as you begin lifesaving measures You are caring for a patient who was recently diagnosed with type 1 diabetes. She is learning to manage her diabetes and will need support after discharge. Her knowledge deficit is considered a _____________ priority problem and will require a collaborative effort with health care professionals. a. First-level b. Second-level c. Third-level c. Third-level You completed the health history and physical examination on your new admission. After completing the assessment phase of the nursing process, the next step includes which of the following? a. Interpreting clinical findings and determining a diagnosis b. Clustering cues and evaluating assessment data c. Collaborating with the patient and reviewing information d. Evaluating the information collected and determining next steps a. Interpreting clinical findings and determining a diagnosis G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. Blood pressure 74/50, HR 148 __________ first G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. Serum potassium 2.7 mmol/L (low), Glucose 225 mg/dL (high) __________ second G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. Lives alone, no family in the area __________ third G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. Acute chest pain with radiation to jaw __________ second G.R. is a 75-year-old male who presents to the emergency department with chest pain, palpitations, and appears pale and diaphoretic. As the history and physical are completed, the following problems emerge. Please label them first-, second-, or third-level priority problems. Unfamiliar with heart-healthy dietary guidelines __________ third Which of the following are objective data? Select all that apply. a. 2-cm scar on dorsal surface of the hand b. Complaints of nausea c. Clear breath sounds d. Headache e. BP 110/72 a. 2-cm scar on dorsal surface of the hand c. Clear breath sounds e. BP 110/72 S.Q. has cellulitis due to a cat scratch. She missed multiple appointments and didn't take her medication. S.Q. lost her job, sleeps on her sister's couch, lives in a food desert, and eats from gas stations or fast-food restaurants. She missed follow-up visits due to transportation issues and couldn't afford the antibiotics. Which factor best describes what is influencing her well-being? a. S.Q. is not motivated to be compliant with health care provider recommendations. She should make sure she attends all appointments. b. Social determinants of health, including lack of economic stability and an environment that lacks nutritious food options, are negatively impacting S.Q. c. Social determinants of health are important, but she can overcome these barriers if she tries hard enough. d. S.Q. should work harder to get a new job so she has improved economic stability and may be able to become self-sufficient. b. Social determinants of health, including lack of economic stability and an environment that lacks nutritious food options, are negatively impacting S.Q. Evidence-based nursing practice is: a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances b. Appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices d. Finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances Which statement best describes religion? a. An organized system of beliefs concerning the cause, nature, and purpose of the universe b. Belief in a divine or superhuman spirit to be obeyed and worshiped c. Affiliation with one of the 1200 recognized religions in the United States d. The following of established rituals, especially in conjunction with health-seeking behaviors a. An organized system of beliefs concerning the cause, nature, and purpose of the universe The major factor contributing to the need for cultural care nursing is: a. An increasing birth rate. b. Limited access to health care services. c. Demographic change. d. A decreasing rate of immigration. c. Demographic change. You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional, respectful demeanor b. Allowing for additional time to complete the process c. Providing the patient with a paper and pencil so answers can be written d. Obtaining interpreter services so the family does not need to translate c. Providing the patient with a paper and pencil so answers can be written The first step to cultural competency by a nurse is to: a. Identify the meaning of health to the patient. b. Understand how a health care delivery system works. c. Develop a frame of reference to traditional health care practices. d. Understand their heritage and its basis in cultural values. d. Understand their heritage and its basis in cultural values. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with a patient? a. "Are you of the Christian faith?" b. "Do you want to see a medicine man?" c. "How often do you seek help from medical providers?" d. "What cultural or spiritual beliefs are important to you?" d. "What cultural or spiritual beliefs are important to you?" Which statement best reflects the biomedical causation of illness? a. Each being is only a part of a larger structure in the world of nature as it relates to health and illness. b. Causal relationship exists, leading to expression of illness. c. Belief in the struggle between good and evil is reflected in the regulation of health and illness. d. Illness occurs as a result of disturbances between hot and cold reactions. b. Causal relationship exists, leading to expression of illness. You are caring for a Jewish patient who needs a leg amputation. The patient is concerned about what will happen to the leg after amputation and becomes visibly distraught when you inform him it will be disposed of by the hospital. What should you do? a. Provide information on postoperative prosthetics so he understands that loss of the limb does not limit physical ability. b. Provide education on the surgical procedure and what to expect in the immediate post-operative period so he feels more prepared. c. Ask if he would like you to contact friends, family, or the hospital chaplain so he can talk about how he feels. d. Ask about his cultural beliefs and whether there is anything the hospital can do to support him before, during, and after surgery. d. Ask about his cultural beliefs and whether there is anything the hospital can do to support him before, during, and after surgery. You are a nurse in the university health center. You notice that X.L. is on your list for the fourth time in the past three months. Her previous complaints include weight loss and fatigue. Today, she is in the clinic for irregular periods and appears pale with hollow cheekbones. She is a 19-year-old first-year student with an uneventful past medical history. She is a first-generation college student whose parents immigrated from Iran 20 years ago. What questions should be included in a cultural assessment? Select all that apply. a. Are there any foods that you are unable to eat due to cultural beliefs? b. Are you using any complementary or alternative treatments currently? c. Could pregnancy be the reason for your irregular periods and illness? d. What is your favorite food to eat? e. How are you doing in your classes? Have you been able to make friends? a. Are there any foods that you are unable to eat due to cultural beliefs? b. Are you using any complementary or alternative treatments currently? During further investigation you discover that X.L. follows a Halal diet. You know very little about the diet. What is the most appropriate next step? a. Ask X.L. about the diet she follows and whether she has access to appropriate food in the university dining facility. b. Complete a physical assessment to determine the cause of her progressive symptoms. c. Make a note of the diet in her chart and plan to do research on the diet prior to seeing your next patient. d. Complete a thorough health history to determine if she has experienced any changes in health since her last appointment. a. Ask X.L. about the diet she follows and whether she has access to appropriate food in the university dining facility. During report on a 39-year-old Hispanic male, you learn that the patient had surgery yesterday but has refused all pain medication and denies any pain. As you assess the patient, you notice an elevated heart rate and blood pressure as well as grimacing with abdominal palpation, but the patient continues to deny pain. You: a. continue the assessment believing that if a patient is in pain, they will tell you. b. recognize that pain expression may vary based on culture and that all Hispanic men do not take pain medications c. recognize that pain expression may vary based on culture and ask appropriate cultural assessment questions d. recognize that men do not respond to pain the same way as women, and they may not feel pain the same way c. recognize that pain expression may vary based on culture and ask appropriate cultural assessment questions You are caring for a patient who requests that a shaman (medicine man) visit him while he is hospitalized. He would like a smudging ritual completed prior to his upcoming treatment. You know that smudging involves the burning of sage. Your best response is: a. We cannot allow that ritual in the hospital because we do not allow open flames. b. Call your shaman and have him come any time. Just make sure to close the door. c. Let's work with the shaman to determine the best way to complete the ritual in a safe manner. d. Don't worry. Dr. Smith is the best, so you have nothing to worry about. c. Let's work with the shaman to determine the best way to complete the ritual in a safe manner. The practitioner, entering the examining room to meet a patient for the first time, states: "Hello, I'm M.M., and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it's all right with you, she will remain during the examination." Which of the following must be added to cover all aspects of the interview contract? a. A statement regarding confidentiality, patient costs, and the expectations of each person b. The purpose of the interview and the role of the interviewer c. Time and place of the interview and a confidentiality statement d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies a. A statement regarding confidentiality, patient costs, and the expectations of each person Which of the following are open-ended questions? Select all that apply. a. Tell me about your headaches. b. Describe your chest pain. c. Point to where the pain is. d. What do you expect from me as your nurse? e. Do you want to discuss all your options? a. Tell me about your headaches. b. Describe your chest pain. d. What do you expect from me as your nurse? M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse? a. "Tell me what prompted that question." b. "I will ask your physician to discuss this matter with you." c. "Let's take each day as it comes." d. "I think you should discuss that with your family." a. "Tell me what prompted that question." When teaching a client how to effectively manage their new medication regimen, the nurse recognizes that the best method of communicating therapeutically with the client is to: a. Talk to the client in the visitors' lounge b. Talk to the client within his personal space c. Communicate with the client using touch d. Face the client while leaning slightly forward d. Face the client while leaning slightly forward Factors important during an interview include: Select all that apply. a. Equal status seating b. Leading questions c. Active listening d. Distancing e. Social responses f. Avoidance language g. Providing privacy h. Professional jargon a. Equal status seating c. Active listening g. Providing privacy You are preparing to do the initial interview with a 15-year-old patient. In order to establish rapport, you: a. Begin the interview by immediately discussing the health concern. Adolescents do not want small talk and want to finish as quickly as possible. b. Begin the interview by completing the full health history and discussing drug/alcohol use. Adolescents want to finish as quickly as possible. c. Begin the interview by asking open, friendly questions about school and hobbies. Adolescents appreciate the opportunity to discuss themselves. d. Begin the interview by asking open-ended questions that explore the health history. Adolescents are knowledgeable, and you can speak to them like adults. c. Begin the interview by asking open, friendly questions about school and hobbies. Adolescents appreciate the opportunity to discuss themselves. You work in the emergency department, and an 88-year-old Spanish-speaking patient was just brought by ambulance with chest pain. You do not speak Spanish and there is no in-person interpreter available. Your best option to ensure communication is: a. Identify a friend or family member who can provide interpreter services. It's better to have someone in person. b. Leverage technology to ensure communication. Your hospital recently invested in video interpreter services. c. Use gestures, simple words, and a loud voice to work through the history and physical exam. d. Call another floor and see if they have anyone who knows Spanish. The patient can probably wait for a while. b. Leverage technology to ensure communication. Your hospital recently invested in video interpreter services. Mark each of the following statements as therapeutic or nontherapeutic. I'm sure everything will be fine. You sound upset. Please tell me more about what happened today. Dr. Daniels knows what he is talking about. Just follow his recommendations. What are the pros and cons of surgery? If I were you, I would get another opinion before having surgery. Why did you wait so long to see the doctor after the symptoms began? You must not eat or drink anything after midnight except for small sips of water to take your morning pills. No need to cry. Let's move on to a different topic. THERAPEUTIC -You sound upset. Please tell me more about what happened today. -What are the pros and cons of surgery? -You must not eat or drink anything after midnight except for small sips of water to take your morning pills. NONTHERAPEUTIC -I'm sure everything will be fine. -Dr. Daniels knows what he is talking about. Just follow his recommendations. -If I were you, I would get another opinion before having surgery. -Why did you wait so long to see the doctor after the symptoms began? -No need to cry. Let's move on to a different topic. Nonverbal behaviors are just as important as verbal behaviors. Please mark the following behaviors as positive or negative. Tapping a pen rhythmically on the table. Warm smile while leaning slightly forward. Moderate tone of voice and rate of speech. Frequently crossing and uncrossing legs. Arms crossed over chest. Standing by the client's bed. POSITIVE -Warm smile while leaning slightly forward. -Moderate tone of voice and rate of speech. NEGATIVE -Tapping a pen rhythmically on the table. -Frequently crossing and uncrossing legs. -Arms crossed over chest. -Standing by the client's bed. A pregnant woman explains that she does not intend to stop drinking because her friends continued to drink during pregnancy and "nothing happened to them or their kids." How should the clinician respond to this statement? a. "While it's true that there is no scientific evidence that alcohol harms the fetus, abstinence is recommended because of the physical effects on your body." b. "No amount of alcohol has been determined to be safe for a pregnant woman so I would recommend you stop drinking alcohol completely." c. "Maybe you could cut back on your alcohol intake, at least until you're in the third trimester, when the effects on the fetus are minimal." d. "If you can limit yourself to only one drink per day, you will be helping yourself and your baby." b. "No amount of alcohol has been determined to be safe for a pregnant woman so I would recommend you stop drinking alcohol completely." You are screening for alcohol use in a 45-year-old male who reports an increase in drinking after being laid off. Which of the following statements would be indicative of exceeding the recommended limit? a. "I used to go out after work on Fridays with my friends. Now I drink a beer most nights of the week." b. "I used to go out after work on Fridays with my friends. Now I have three or four beers most nights." c. "I used to go out after work on Fridays with my friends. Now I don't drink at all since I don't go out after work." d. "I used to go out after work on Fridays with my friends. Now I have two beers most nights." b. "I used to go out after work on Fridays with my friends. Now I have three or four beers most nights." You are assessing a male patient's alcohol consumption. Which statement would alert you to investigate further? a. "I drink at wedding and holidays." b. "I enjoy a few beers on the weekend." c. "No matter how much I drink I don't get drunk." d. "I drink a beer with dinner every day." c. "No matter how much I drink I don't get drunk." A patient reports drinking alcohol but abstains from illicit substances. The CAGE questionnaire reveals he sometimes thinks he should cut down on drinking and occasionally needs a drink in the morning to get going. Based on this assessment, what should you tell the patient? a. While I don't think you should drink in the morning, your drinking does not seem to be impacting your work or home life. You might consider cutting down, though. b. I would recommend keeping a journal of how much you drink. That way, when you come back, we can have a discussion of drinking patterns. c. I believe you may have an alcohol use disorder. I am here to help and would like to identify some treatment options. d. I believe you have an alcohol use disorder. You must stop drinking now or you will likely die early. c. I believe you may have an alcohol use disorder. I am here to help and would like to identify some treatment options. Which of the following physiologic changes put older adults at higher risk when consuming alcohol? Select all that apply. a. Decrease muscle mass b. Increase body water c. Decrease body water d. Decreased kidney function e. Increase in liver metabolism f. Higher metabolism a. Decrease muscle mass c. Decrease body water d. Decreased kidney function You are caring for a newly admitted patient in the intensive care unit. He is alert and oriented after being in a car accident. He has multiple injuries including bilateral broken femurs, fracture of T10, and multiple lacerations. While completing his intake questionnaire, you recognize the importance of screening for alcohol use and will proceed in the following manner: a. Ask how often and how much he drinks. This is not the time to ask any further questions. b. Recognize that alcohol withdrawal is a potential complication, and ask him the AUDIT-C questionnaire. c. Recognize that alcohol withdrawal is a potential complication, and ask him the AUDIT questionnaire. d. Proactively place him on CIWA-Ar precautions because he was in a car accident and is likely unreliable. b. Recognize that alcohol withdrawal is a potential complication, and ask him the AUDIT-C questionnaire. Which of the following is a standard drink? Select all that apply. a. 5 oz of table wine b. 1.5 oz of hard liquor (e.g., gin, vodka) c. 12 oz can of malt liquor (12% ABV) d. One martini e. 12 oz can of beer (5% ABV) f. Pint of beer g. 1⁄2 bottle of a standard table wine a. 5 oz of table wine b. 1.5 oz of hard liquor (e.g., gin, vodka) e. 12 oz can of beer (5% ABV) For each of the following items, specify whether it is a characteristic of intoxication with each substance. Some characteristics may describe more than one. Alcohol Marijuana Opiates Cocaine Pinpoint pupils Reddened eyes Pupillary dilation Loss of balance Slurred speech Talkativeness ALCOHOL Loss of balance Slurred speech Talkativeness MARIJUANA Reddened eyes Loss of balance OPIATES Pinpoint pupils Slurred speech COCAINE Pupillary dilation Talkativeness For each item below, specify whether it is a characteristic of withdrawal from each substance. Some characteristics may describe more than one. Alcohol Marijuana Opiates Cocaine Irritability Dilated pupils Hallucinations Fatigue Hand tremors ALCOHOL Irritability Hallucinations Hand tremors MARIJUANA Irritability OPIATES Irritability Dilated pupils COCAINE Irritability Fatigue Bruising on a nonwalking or noncruising child: a. Is a common finding from normal infant activity. b. Needs to be further evaluated for either an abusive or medical explanation. c. Is commonly seen on the buttocks. d. Is not uncommon because infants bruise easily. b. Needs to be further evaluated for either an abusive or medical explanation. During an examination, you notice a patterned injury on a 10-year-old patient's back. There are linear ecchymoses on the back but no other signs of bruising and no history of blood dyscrasia. Upon discussion with the parents, they tell you that their child has a bad cold with a high fever and they have been working to release the negative energies associated with the illness by using coining. Given your knowledge of cultural practices, you recognize that: a. Coining is practiced in Chinese and Southeast Asian cultures and is not considered effective unless it leaves bruises. b. Coining is a form of child abuse because it has no medical benefit so the parents should be reported immediately for abuse. c. Coining is a cultural practice but should not leave bruises on the skin. The child needs to be evaluated for abuse. d. Coining is a common practice that is safe and effective in treating fever and colds. a. Coining is practiced in Chinese and Southeast Asian cultures and is not considered effective unless it leaves bruises. During an interview, a woman received a score of 11 on the Hurt, Insult, Threaten, Scream (HITS). What is the best way to proceed with the interview and subsequent assessment? a. Ask the patient if she is being abused and whether she has contacted the authorities. b. Proceed by asking more questions about potential abuse and refer to appropriate social support services. c. Tell the patient you believe she is being abused and tell her you will call the police to file a report. b. Proceed by asking more questions about potential abuse and refer to appropriate social support services. You are working the night shift in the emergency room and just received an unconscious 23-year-old female victim of suspected abuse. Because she is unable to answer questions about her injuries, you should: a. Provide life-saving measures but delay any assessment of injuries until she can answer questions. b. Provide life-saving measures but delay any photographic evidence documentation until she can provide consent. c. Provide life-saving measures and include photographic evidence per hospital protocol even without consent. d. Provide life-saving measures and try to determine the cause of each individual injury as you chart your full assessment. c. Provide life-saving measures and include photographic evidence per hospital protocol even without consent. An adolescent female appears younger than her listed age of 18, is at urgent care for pelvic pain, and her older boyfriend requested a pregnancy test. She is withdrawn and unable to answer basic questions. What actions should you take? Select all that apply. a. Defer to the boyfriend to answer questions because he seems to know what is happening. b. Complete a physical assessment noting any bruising or other signs of trauma. c. Provide a pregnancy test. d. Screen for sexually transmitted infection. e. Separate the patient and her companion to get a more thorough history from the patient. f. Allow the companion to stay in the room to avoid making the patient uncomfortable. b. Complete a physical assessment noting any bruising or other signs of trauma. c. Provide a pregnancy test. d. Screen for sexually transmitted infection. e. Separate the patient and her companion to get a more thorough history from the patient. A 75-year-old male hospitalized with pneumonia reports feeling safe at home but missing $5000 and having his credit card declined. He lives independently, is cognitively intact, and has his son and daughter visit weekly. His daughter has financial troubles. What should you do? a. Contact social work to help with his financial concerns and neurology because he may have dementia because he cannot find his checkbook. b. Follow hospital policy to report suspected elder abuse due to potential financial abuse/exploitation. c. Provide reassurance that he will be discharged soon, and you are sure his checkbook will turn up. d. Encourage him to talk to his daughter about her problems and see if there is anything he can do to help. b. Follow hospital policy to report suspected elder abuse due to potential financial abuse/exploitation. Documentation of suspected abuse should include which of the following. Select all that apply. a. photographic evidence b. subjective descriptions of injuries c. objective descriptions of injuries d. appropriate forensic terminology e. paraphrased account of victim statement without direct quotes f. appropriate direct quotes with some paraphrasing g. direct quotes that remove expletives or potentially offensive language a. photographic evidence c. objective descriptions of injuries d. appropriate forensic terminology f. appropriate direct quotes with some paraphrasing Upon your initial assessment, you note the following: minute, pinpoint, nonraised round spots behind the ear; dark purple discoloration of the right eye and cheek; a burn that encompasses the entire right hand; and a 2-inch cut on the right cheek. The appropriate forensic terms that you will use in documentation are: Select all that apply. a. incision b. puncture c. alopecia d. patterned injury e. avulsion f. ecchymosis g. abrasion h. petechiae a. incision d. patterned injury f. ecchymosis h. petechiae You are completing an intake assessment of an 18-month-old male who is in the clinic for his well-baby check. You note that he is walking around the chairs in the exam room, smiling, laughing, and appears at ease with his caregiver. He is able to walk without assistance but falls when he gets excited and tries to run. Upon physical examination you notice bruises on his legs bilaterally and his arms. He also has a bruise in the middle of his forehead. The caregiver reports that he ran into the coffee table 2 days ago and he has since moved it out of the living room to avoid future accidents. You should recognize that the bruises _(are/are not)_____a sign of abuse. Because the toddler is walking, he is __(likely/unlikely)____to have bruises. Noting how the child acts with the caregiver is an ________(effective/ineffective)_______way to assess the caregiver/child relationship. are not, likely, effective You are preparing to assess a 1-month-old who is awake and fussy. Given what you know of development, you begin the assessment by: a. moving in a head-to-toe fashion so you do not forget anything. b. listening to the heart and lungs first while the infant is being held. c. personalizing the assessment based on the infant's temperament. d. avoiding eye contact because the infant has stranger anxiety. c. personalizing the assessment based on the infant's temperament. The nurse is assessing a patient's skin for swelling during an office visit. What is the best technique to use to assess the patient's skin for lumps and swelling? Use the: a. fingertips because they have better tactile discrimination than the rest of the hand. b. dorsal surface of the hand because the skin is thinner than on the palms of the hand. c. ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. d. palmar surface of the hand because it is most sensitive to temperature variations. a. fingertips because they have better tactile discrimination than the rest of the hand. Palpation can be used for which of the following? Select all that apply. a. Position of an organ b. Size of a mass c. Density of an organ d. Deep tendon reflex e. Pulsation f. Vibration a. Position of an organ b. Size of a mass e. Pulsation f. Vibration When percussing over the lungs of a patient, the nurse notices a dull sound. The nurse should: a. consider this a normal finding and continue the assessment. b. palpate this area for an underlying mass. c. reposition the hands and attempt to percuss in this area again to confirm the finding. d. move on with the assessment so as not to alarm the patient. c. reposition the hands and attempt to percuss in this area again to confirm the finding. You are preparing to assess a patient who reports changes in skin pigmentation. The best option for lighting is: a. Natural daylight b. Overhead lighting c. Tangential lighting d. Sun lamp a. Natural daylight Extra heart sounds and murmurs are described as low-pitched sounds. Given your knowledge of the stethoscope, you know that low-pitched sounds are best heard with the: a. bell end piece held firmly to the skin b. bell end piece held lightly against the skin c. diaphragm end piece held firmly to the skin d. diaphragm end piece held lightly to the skin b. bell end piece held lightly against the skin You are preparing to enter the room of a patient with suspected pertussis. To protect yourself and others you will: Select all that apply. a. use standard precautions b. use contact precautions c. use droplet precautions d. use airborne precautions e. use hand sanitizer f. wash your hands with soap and water if visibly soiled g. always wash your hands instead of using hand sanitizer a. use standard precautions c. use droplet precautions e. use hand sanitizer f. wash your hands with soap and water if visibly soiled To assess a patient's abdomen by palpation, how should the nurse proceed? a. Avoid palpation of reported "tender" areas because this may cause the patient pain. b. Quickly palpate a tender area to avoid any discomfort that the patient may experience. c. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Define and describe the technique of the four physical examination skills: 1) Inspection Inspection is a method of concentrated watching, involving close and careful scrutiny of the individual as a whole and each body system. It starts the moment you first meet the person, forming a "general survey." Key Points: -Begin with an initial general survey of the person. -Initial impressions from greetings and handshakes can provide important information. -Each body system assessment starts with inspection. -Inspection always comes first and should be done thoroughly. -Train yourself to avoid rushing by holding your hands behind your back. -Compare the right and left sides of the body for symmetry. -Use good lighting, adequate exposure, and sometimes instruments like an otoscope, ophthalmoscope, penlight, or specula for better viewing. Define and describe the technique of the four physical examination skills: 2) Palpation Purpose: Confirms inspection findings using touch. Factors Assessed: Texture, temperature, moisture, organ location/size, swelling, vibration, pulsation, rigidity, spasticity, crepitation, lumps, tenderness, pain. Hand Techniques: Fingertips: Fine tactile discrimination (texture, swelling, pulsation, lumps). Grasping (fingers/thumb): Position, shape, consistency of organs/masses. Dorsa (backs of hands): Temperature. Base of fingers/ulnar surface: Vibration. Procedure: Warm hands. -Start with light palpation, then deeper palpation. -Identify and palpate tender areas last. -Use intermittent pressure for deep palpation. -Encourage patient relaxation (imagery, deep breathing). -Avoid causing internal injury/pain. -Bimanual palpation for precise delimitation of organs (e.g., kidneys, uterus). Define and describe the technique of the four physical examination skills: 3) Percussion Technique: Tapping the skin with short, sharp strokes to assess underlying structures. Produces audible vibrations and characteristic sounds. Uses: Mapping Organ Location/Size: Identifying changes in percussion notes between organ borders. Density Signaling: Determining if a structure is air-filled, fluid-filled, or solid. Mass Detection: Detecting superficial abnormal masses (up to 5 cm deep). Reflex Elicitation: Using a percussion hammer to test deep tendon reflexes. Define and describe the technique of the four physical examination skills: 4) Auscultation Purpose: Listening to body sounds (heart, blood vessels, lungs, abdomen). Equipment: Stethoscope blocks extraneous sounds. Endpieces: Diaphragm (high-pitched sounds) and bell (low-pitched sounds). Tunable diaphragm: Light pressure for low-frequency, firm pressure for high-frequency sounds. Procedure: Ensure a quiet, warm room. Warm the stethoscope. Clean endpiece with an alcohol wipe. Wet chest hair to reduce crackling sounds. Avoid listening through clothing. Minimize self-made artifacts (breathing on tubing, jewelry noise). Technique: Learn normal sounds first. Listen selectively, focusing on one sound at a time. Identify and differentiate normal and abnormal sounds. Define the characteristics of the following percussion notes: Pitch Amplitude Quality Duration Resonance Hyperresonance Tympany Dull RESONANCE Pitch: Low Amplitude: Medium loud Quality: clear, hollow Duration: Moderate Sample Location: over normal lung tissue HYPERRESONANCE Pitch: Lower Amplitude: Louder Quality: Booming Duration: Longer Sample location: Normal over child's lung; Abnormal in the adult, over lungs with increased amount of air as in emphysema TYMPANY Pitch: Lower Amplitude: Loud Quality: Musical and drumlike (like the kettledrum) Duration: Sustained longest Sample location: Over air-filled viscus (e.g., the stomach, the intestine) DULL Pitch: High Amplitude: Soft Quality: Muffled thud Duration: Short Sample location: Relatively dense organ as liver or spleen Differentiate among light, deep, and bimanual palpation. - *Light Palpation:* - *Purpose:* Assess surface characteristics and accustom the patient to being touched. - *Technique:* Use gentle pressure with fingertips. - *Depth:* Approximately 1 cm. - *Deep Palpation:* - *Purpose:* Assess deeper structures and organs. - *Technique:* Use firmer pressure with one or both hands, applying intermittent pressure. - *Depth:* Approximately 4-5 cm. - *Bimanual Palpation:* - *Purpose:* Envelop or capture certain body parts or organs for more precise assessment. - *Technique:* Use both hands to palpate, with one hand applying pressure and the other feeling the underlying structure. - *Uses:* Commonly used for assessing organs like kidneys, uterus, or adnexa. You are caring for a 36-year-old male who presents to the emergency department with acute right lower quadrant abdominal pain rated at 10/10 on the numeric pain rating scale. The patient is tachycardic, tachypneic, grimacing, and curled in the fetal position. During the workup, the provider refuses to order any pain medication. You should: a. Advocate for the patient to receive pain medication. It will be easier to complete the workup if the patient is comfortable. b. Let the patient know that no pain medication can be given until the workup is complete, as the medication may mask symptoms. c. Recognize that the provider understands the need for the patient to feel the pain so he can adequately describe it. d. Call your supervisor to intervene. The patient should have pain medication ordered immediately. a. Advocate for the patient to receive pain medication. It will be easier to complete the workup if the patient is comfortable. A patient has osteoarthritis in her hips and knees. She can move around in her room this morning and has offered no complaints. When asked, she states that her pain is "bad this morning" and rates the pain at an 8 on a 0 to 10-point scale. The nurse suspects the patient: a. Is addicted to her pain medication and cannot obtain relief from small doses. b. Does not want to trouble anyone with her complaints. c. Is not in severe pain but would like pain medication. d. Has experienced pain for years and adapted to the chronic pain. d. Has experienced pain for years and adapted to the chronic pain. Acute and chronic pain result in a variety of physiological changes. Mark the following as a result of acute pain or chronic pain. Depression Nausea Fear Isolation Limited functioning Tachycardia ACUTE PAIN Nausea Fear Tachycardia CHRONIC PAIN Depression Isolation Limited functioning A non-English speaking client enters the clinic and repeats the word "doctor." What can the nurse do to assist this client? a. Repeat the word "doctor" back to the client. b. Assist this client to a chair in the waiting room. c. Tell the client to sign the sign-in sheet. d. Discuss this with the healthcare provider. d. Discuss this with the healthcare provider. This question demonstrates that the nurse does not have enough cultural information to assist this client. The only real choice is for the nurse to discuss this with the healthcare provider, who might be better able to assist the client. Repeating the word, assisting the client back to the waiting room, and having the client sign the sign-in sheet are not appropriate actions in this situation. A female Latino client turns to her husband when the nurse asks a question about her health. The nurse realizes that this client is demonstrating which type of culture? a. Material b. Non material c. Competence d. Incomplete b. Non material Non material culture is composed of the verbal and nonverbal language, beliefs, customs, and social structures. Material culture includes things such as dress, art, utensils, and tools and the ways they are used. Competence and incomplete are not types of culture. A Spanish-speaking client needs educational materials about hepatitis. What is the best action for the nurse to take to help this client? a. Provide the client with the instructions written in English. b. Contact an interpreter to read the printed English instructions to the client in Spanish. c. Tell the client that instructions do not exist for that health problem. d. Determine that the client does not need the information. b. Contact an interpreter to read the printed English instructions to the client in Spanish. instructions to the client in Spanish. According to the National Standards for Culturally and Linguistically Appropriate Services in Healthcare, Standard 6 states that all clients with limited English proficiency (LEP) are to be provided access to bilingual staff or interpretation services. If instructions are not available written in Spanish, the next best thing is to ask an interpreter to read the English instructions to the client in Spanish. Providing the instructions in English, telling the client that instructions are not available for that health problem, or deciding that the client doesn't need this information are not appropriate nursing actions in this situation. The nurse is observed talking rudely to a client who is an immigrant. When approached about this behavior, the nurse responds, "These people should stay in their own country." This nurse is demonstrating: a. competent cultural care b. ethnocentrism c. material culture d. nonmaterial culture b. ethnocentrism Ethnocentrism is the tendency to believe that one's own beliefs, way of life, values, and customs are superior to those of others. This can interfere with collection and interpretation of data as well as the development of plans of care to meet client needs. Competent cultural care includes understanding and planning for the needs of culturally diverse clients or groups. Material culture includes objects such as art and dress. Non material culture is composed of language, beliefs, The teenager of immigrant parents tells the nurse, "I have to make sure my parents don't find out about my friends and that we play video games after school. It would be disgraceful." The nurse realizes this client is demonstrating: a. assimilation b. diversity c. race d. ethnocentrism a. assimilation Assimilation refers to the adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture. Assimilation occurs more easily in second-generation immigrants. Diversity is the state of being different. Race refers to the identification of an individual or group by shared genetic heritage and biological and physical characteristics. Ethnocentrism is the tendency to believe that one's own beliefs are superior to those of others. An Arab American tells the nurse, "I am sick because that man on the bus gave me the evil eye." The nurse realizes this client is demonstrating: a. a temporal relationship b. a communication pattern c. a health belief d. a health practice c. a health belief Within the Arab American culture, one health belief is that illness is caused by the evil eye. This is an example of a magico-religious belief system. A temporal relationship refers to time orientation such as past, present, or future. Health practices are influenced by health beliefs, knowledge, and culture. Communication patterns refer to verbal and nonverbal communication methods. The mother of an Appalachian infant tells the nurse that the baby has been having colic ever since she started feeding him sweet coffee. What would be an appropriate response for the nurse to make to this mother? a. "Coffee to an infant?" b. "Your baby is too young to digest the milk in the coffee." c. "How much sugar did you use?" d. "Tell me more about giving sweet coffee to your baby." d. "Tell me more about giving sweet coffee to your baby." One dietary habit of Appalachians is the introduction of coffee to infants at an early age. The nurse needs to recognize that this is a normal dietary custom and offer suggestions as to why the infant may not be tolerating the food item. Inquiries concerning milk and sugar do not address the reasons for the problems being experienced by the infant. A female Chinese client states, "I will say nothing until my husband comes in from parking the car." The nurse realizes this client is demonstrating: a. a temporal relationship b. a health belief c. a family pattern d. a health practice c. a family pattern The family pattern within Chinese Americans is one of male dominance. Family patterns include role and relationship patterns within a family. Temporal relationship refers to time orientation (past, present, future). Health beliefs include magico-religious, biomedical, and holistic beliefs. Health practices are influenced by the individual's health beliefs, knowledge, and culture. A Cuban American tells the nurse, "The remedy didn't work, so I am here to find more help." The nurse realizes this client is demonstrating: a. a health belief b. a health practice c. a dietary habit d. a temporal relationship a. a health belief The health beliefs of many Cuban Americans include the use of herbs, rituals, and ceremonies to diagnose and cure illnesses. Health practices are influenced by an individual's health beliefs as well as culture and knowledge. Dietary habit information is not discussed in the question. Temporal relationships refer to an individual's or group's orientation in terms of past, present, or future. A Native American tells the nurse, "The medicine man told me that I am imbalanced and gave me pellets to use every day for 3 weeks." The nurse realizes this client is describing: a. a health belief b. a dietary habit c. a temporal relationship d. a health practice d. a health practice One health practice of the Native American is the use of medicine men to diagnose and treat disharmony. Health beliefs are one's beliefs about the causes of health and illness. Dietary habit information is not discussed in the question. Temporal relationships refer to an individual's or group's orientation in terms of past, present, or future. A Vietnamese American is 2 hours late for a clinic appointment and tells the nurse, "I wrote down 1 when the person on the phone told me to write down 1. After repeating it two times I thought the nurse was just making sure I got the number right." The nurse realizes this miscommunication error is an example of: a. a health belief b. language difference c. nonverbal communication d. a health practice b. language difference Language differences can result in the inability to make telephone contact and to understand dates, times, and locations for appointments. Health beliefs are one's beliefs about the causes of health and illness. Nonverbal communication consists of gestures, facial expressions, and mannerisms that occur during interactions with others. Health practices are what the individual does to promote health. They are influenced by health beliefs, knowledge, and culture. A Filipino American sits with arms crossed yet nods as the nurse provides healthcare information. The nurse realizes this client is demonstrating: a. agreement about the plan of care b. rude behavior to the nurse c. the need for an interpreter d. hearing the nurse talking d. hearing the nurse talking Filipino Americans often nod the head during communication, which may appear to indicate agreement or understanding but may simply mean, "I hear you." Nodding of the head does not indicate agreement with the plan of care, nor demonstrate rude behavior or the need for an interpreter. An older adult tells the nurse, "I will not worry about getting sick because it is all in God's will." The nurse realizes this client is demonstrating: a. a holistic health belief b. a temporal relationship c. a magico-religious health belief d. a biomedical health belief c. a magico-religious health belief In a magico-religious belief system, health and illness are believed to be controlled supernaturally or are seen as "God's will." In a holistic health belief system, one holds that human life must be in harmony with nature and that illness results from disharmony between the two. The biomedical health belief model considers illness to be caused by physiological processes. Temporal relationships relate to the individual's past, present, and future orientation. When using an interpreter to communicate with a client whose primary language is one other than English, the nurse should: Select all that apply. a. arrange the seating so that the client cannot see the interpreter b. direct the conversation to the client c. ask questions one at a time d. avoid medical jargon and terminology e. ask the family of the client to interpret b. direct the conversation to the client c. ask questions one at a time d. avoid medical jargon and terminology When using an interpreter, the nurse should direct the conversation to the client, not the interpreter. Questions should be asked slowly and one at a time. The nurse should avoid using medical jargon and medical terminology and use words the client can understand. Seating should be arranged so that the client can see both the nurse and interpreter. Family members should not be used unless requested by the client. Which measures should the nurse take to communicate effectively with a patient? Select all that apply. 1. Provide bright lighting in the communication room. 2. Avoid standing while communicating with the patient. 3. Avoid facing a patient across a desk during communication. 4. Keep 4 to 5 feet of distance with the patient during communication. 5. Avoid placing the chairs at a 90-degree angle during communication. 2. Avoid standing while communicating with the patient. 3. Avoid facing a patient across a desk during communication. 4. Keep 4 to 5 feet of distance with the patient during communication. Which is the primary purpose of interviewing a patient? a. To allow the patient to become acquainted with the nurse. b. To teach preventive health care methods to the patient. c. To get the patient's health history and current health status. d. To correlate the patient's complaints with objective signs. c. To get the patient's health history and current health status. While interviewing a patient, the nurse observes that the patient is taking frequent and long pauses while speaking and that the speech is slow, monotonous, and weak. Which would the nurse infer from this observation? a. Shyness b. Anxiety c. Depression d. Hearing impairment c. Depression A patient who is scheduled for a fasting blood test asks the nurse for a cup of juice, to which the nurse responds, "You should avoid eating or drinking liquids or solids for 12 hours before the test because food may alter the blood test results." Which type of verbal response would the nurse's statement indicate? a. Empathy b. Clarification c. Explanation d. Confrontation c. Explanation Which is an effective communication technique to implement during a clinical interview? a. Use of leading questions b. Avoiding eye contact c. Active listening d. Giving advice c. Active listening Which are the internal factors related to communication? Select all that apply. a. Liking others b. Ensuring privacy c. Listening ability d. Providing empathy e. Refusing interruptions f. Self-awareness a. Liking others c. Listening ability d. Providing empathy f. Self-awareness Which actions would the nurse perform to communicate effectively with a bedridden patient? Select all that apply. a. Maintain proper eye contact b. Speak loudly to the patient c. Refrain from standing in front of the patient d. Avoid focusing on writing notes while interviewing e. Ask only closed-ended questions during the interview a. Maintain proper eye contact c. Refrain from standing in front of the patient d. Avoid focusing on writing notes while interviewing Which statement by the nurse is a reflective response to a pregnant patient who says, "I cannot think of being on bed rest now because I have kids at home and I'm worried about them"? a. "You feel worried and anxious about your children." b. "You must be finding it hard to stay away from the children." c. "You feel worried about your children because you love them a lot." d. "You have to control your emotions because it may affect your health." a. "You feel worried and anxious about your children." Which characteristic behaviors of the nurse suggest an interest in what a patient is saying during an interview? Select all that apply. a. Nodding b. Sitting quietly c. Leaning forward d. Maintaining eye contact e. Asking questions on other topics a. Nodding c. Leaning forward d. Maintaining eye contact The nurse uses the Situation, Background, Assessment, and Recommendation (SBAR) framework when reporting to a primary health care provider about a patient's condition. The nurse reports that the patient needs a central venous access because the peripheral veins are collapsed. Which element of the SBAR would the nurse's statement reflect? a. Situation b. Background c. Assessment d. Recommendation d. Recommendation In which situations would the nurse use the Situation, Background, Assessment, and Recommendation (SBAR) framework for communication? Select all that apply. a. Recording vital signs in the patient's chart b. Organizing assessment findings on the admission form c. Informing a nurse in another unit about the patient's transfer d. Calling the health care provider to report the patient's condition e. Giving nursing shift reports to other nurses working the next shift c. Informing a nurse in another unit about the patient's transfer d. Calling the health care provider to report the patient's condition e. Giving nursing shift reports to other nurses working the next shift Which patient data must be conveyed to the health care provider when using the Situation, Background, Assessment, and Recommendation (SBAR) framework? Select all that apply. a. Vital parameters b. Signs and symptoms c. Past medical history d. Current medications e. Previous hospitalizations a. Vital parameters b. Signs and symptoms d. Current medications SBAR helps in effective communication among health care professionals. Patient information should be current and related to the patient's immediate problems. The BAR should include information regarding the signs and symptoms that the patient is experiencing. It helps understand the patient's condition better.Information about current medications helps in revising treatment and should be included. Information about vital parameters is important to decide whether the patient is stable or whether immediate intervention is needed. Information about past medical history and previous hospitalizations is not related to the present condition and should be excluded. The Situation, Background, Assessment, and Recommendation (SBAR) framework provides which advantages to verbal reporting? Select all that apply. a. Keeps the message concise b. Focuses on the patient's immediate problem c. Rep