HEALTH ASSESSMENT EXAM 2
PRACTICE QUESTIONS NSG3160 AND
SOLUTIONS.
During a mental status assessment, which question by the nurse would best assess a
bb bb bb bb bb bb bb bb bb bb bb bb bb
person's judgment?
bb bb
A "Do you feel that you are being watched, followed, or controlled?"
bb bb bb bb bb bb bb bb bb bb bb
B "What would you do if you found a stamped, addressed envelope lying on the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
sidewalk?"
bb
C "What does the statement, 'People in glass houses shouldn't throw stones,' mean to
bb bb bb bb bb bb bb bb bb bb bb bb bb
you?"
bb
D "Tell me what you plan to do once you are discharged from the hospital." -
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
ANSWER: D "Tell me what you plan to do once you are discharged from the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
hospital."
bb
The nurse is conducting a patient interview. Which statement made by the patient
bb bb bb bb bb bb bb bb bb bb bb bb
should the nurse more fully explore to assess the mental status during the interview?
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
A "I have no health problems."
bb bb bb bb bb
B "I never did too good in school."
bb bb bb bb bb bb bb
C "I am not currently taking any medications."
bb bb bb bb bb bb bb
D "I sleep like a baby." - ANSWER: B "I never did too good in school."
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
During an examination, the nurse can assess mental status by which activity?
bb bb bb bb bb bb bb bb bb bb bb
A Observing the patient as he or she performs an intelligence quotient (IQ) test
bb bb bb bb bb bb bb bb bb bb bb bb bb
B Examining the patient's response to a specific set of questions
bb bb bb bb bb bb bb bb bb bb
C Observing the patient and inferring health or dysfunction
bb bb bb bb bb bb bb bb
D Examining the patient's electroencephalogram - ANSWER: C Observing the patient
bb bb bb bb bb bb bb bb bb bb
and inferring health or dysfunction
bb bb bb bb bb
,When taking the health history on a patient with a seizure disorder, the nurse
bb bb bb bb bb bb bb bb bb bb bb bb bb
assesses whether the patient has an aura. Which of these would be the best
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
question for obtaining this information?
bb bb bb bb bb
A "After the seizure, do you spend a lot of time sleeping?"
bb bb bb bb bb bb bb bb bb bb bb
B "Do you have any warning sign before your seizure starts?"
bb bb bb bb bb bb bb bb bb bb
C "Do you experience any color change or incontinence during the seizure?"
bb bb bb bb bb bb bb bb bb bb bb
D "Does your muscle tone seem tense or limp?" - ANSWER: B "Do you have any
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
warning sign before your seizure starts?
bb bb bb bb bb bb
During the assessment of an 80-year-old patient, the nurse notices that his hands
bb bb bb bb bb bb bb bb bb bb bb bb
show tremors when he reaches for something and his head is always nodding. No
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
associated rigidity is observed with movement. Which of these statements is most
bb bb bb bb bb bb bb bb bb bb bb bb
accurate?
bb
A These findings are normal, resulting from aging.
bb bb bb bb bb bb bb
B These findings could be r/t hyperthyroidism.
bb bb bb bb bb bb
C These findings are the result of Parkinson disease.
bb bb bb bb bb bb bb bb
D This patient should be evaluated for a cerebellar lesion. - ANSWER: A These
bb bb bb bb bb bb bb bb bb bb bb bb bb
findings are normal, resulting from aging.
bb bb bb bb bb bb
A man who was found wandering in a park at 2 AM has been brought to the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
emergency department for an examination; he said he fell and hit his head. During
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
the examination, the nurse asks him to use his index finger to touch the nurse's
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
finger, then his own nose, then the nurse's finger again (which has been moved to a
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
different location). The patient is clumsy, unable to follow the instructions, and
bb bb bb bb bb bb bb bb bb bb bb bb
overshoots the mark, missing the finger. What does the nurse suspect?
bb bb bb bb bb bb bb bb bb bb bb
A Cerebral injury
bb bb
B Peripheral neuropathy
bb bb
C Cerebrovascular accident
bb bb
D Acute alcohol intoxication - ANSWER: D Acute alcohol intoxication
bb bb bb bb bb bb bb bb bb
When assessing the intensity of a patient's pain, which question by the nurse is
bb bb bb bb bb bb bb bb bb bb bb bb bb
appropriate?
bb
A "How does pain limit your activities?"
bb bb bb bb bb bb
B "What does your pain feel like?"
bb bb bb bb bb bb
C "How much pain do you have now?"
bb bb bb bb bb bb bb
D "What makes your pain better or worse?" - ANSWER: C "How much pain do you
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
have now?"
bb bb
The nurse is teaching a class on pain at a local retirement community. Which
bb bb bb bb bb bb bb bb bb bb bb bb bb
statement about the pain experienced by older adults should the nurse include in the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
instructions?
bb
,A "Pain is a normal process of aging and is to be expected."
bb bb bb bb bb bb bb bb bb bb bb bb
B "Pain indicates a pathologic condition or an injury and is not a normal process of
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
aging."
bb
C "Older adults must learn to tolerate pain."
bb bb bb bb bb bb bb
D "Older individuals perceive pain to a lesser degree than do younger individuals." -
bb bb bb bb bb bb bb bb bb bb bb bb bb
ANSWER: B "Pain indicates a pathologic condition or an injury and is not a normal
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
process of aging."
bb bb bb
The nurse is conducting an interview with an adult male patient. Which statement
bb bb bb bb bb bb bb bb bb bb bb bb
made by the patient indicates an alcohol use disorder?
bb bb bb bb bb bb bb bb bb
A "I usually stay out longer and drink more than I intended but I still make it into work
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
on time."
bb bb
B "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
it."
bb
C "I have a strong urge to drink and I've tried to stop drinking several times but it
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
doesn't last long."
bb bb bb
D "I crave alcohol but have successfully cut down on my alcohol consumption." -
bb bb bb bb bb bb bb bb bb bb bb bb bb
ANSWER: C "I have a strong urge to drink and I've tried to stop drinking several
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
times but it doesn't last long."
bb bb bb bb bb bb
The nurse has completed an assessment on a patient who came to the clinic for a leg
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
injury. As a result of the assessment, the nurse has determined that the patient has
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
at-risk alcohol use. Which action by the nurse is most appropriate at this time?
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
A State, "You are drinking more than is medically safe. I strongly recommend that you
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
quit drinking, and I'm willing to help you."
bb bb bb bb bb bb bb bb
B Give the patient information about a local rehabilitation clinic.
bb bb bb bb bb bb bb bb bb
C Record the results of the assessment, and notify the physician on call.
bb bb bb bb bb bb bb bb bb bb bb bb
D State, "It appears that you may have a drinking problem. Here is the telephone
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
number of our local Alcoholics Anonymous chapter." - ANSWER: A State, "You are
bb bb bb bb bb bb bb bb bb bb bb bb bb
drinking more than is medically safe. I strongly recommend that you quit drinking, and
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
I'm willing to help you."
bb bb bb bb bb
During a mental status examination, the nurse wants to assess a patient's affect.
bb bb bb bb bb bb bb bb bb bb bb bb
Which question the nurse should ask?
bb bb bb bb bb bb
, A "Have these medications had any effect on your pain?"
bb bb bb bb bb bb bb bb bb
B "Would you please repeat the following words?"
bb bb bb bb bb bb bb
C "Has this pain affected your ability to get dressed by yourself?"
bb bb bb bb bb bb bb bb bb bb bb
D "How do you feel today?" - ANSWER: D "How do you feel today?"
bb bb bb bb bb bb bb bb bb bb bb bb bb
A woman brings her husband to the clinic for an examination. She is particularly
bb bb bb bb bb bb bb bb bb bb bb bb bb
worried because after a recent fall, he seems to have lost a great deal of his memory
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
of recent events. Which statement reflects the nurse's best course of action?
bb bb bb bb bb bb bb bb bb bb bb bb
A Plan to integrate the mental status examination into the history and physical
bb bb bb bb bb bb bb bb bb bb bb bb
examination.
bb
B Reassure his wife that memory loss after a physical shock is normal and will soon
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
subside.
bb
C Perform a complete mental status examination.
bb bb bb bb bb bb
D Refer him to a psychometrician. - ANSWER: C Perform a complete mental status
bb bb bb bb bb bb bb bb bb bb bb bb bb
examination.
bb
The nurse is providing instructions to a newly hired graduates for the mini-mental
bb bb bb bb bb bb bb bb bb bb bb bb
state examination (MMSE). Which statement best describes this examination?
bb bb bb bb bb bb bb bb bb
A The MMSE is a useful tool for an initial evaluation of mental status. Additional tools
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
are needed to evaluate cognition changes over time.
bb bb bb bb bb bb bb bb
B The MMSE is a good tool to evaluate mood and thought processes.
bb bb bb bb bb bb bb bb bb bb bb bb
C This examination is a good tool to detect delirium and dementia and to differentiate
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
these from psychiatric mental illness.
bb bb bb bb bb
D Scores below 30 indicate cognitive impairment. - ANSWER: C This examination is a
bb bb bb bb bb bb bb bb bb bb bb bb bb
good tool to detect delirium and dementia and to differentiate these from psychiatric
bb bb bb bb bb bb bb bb bb bb bb bb bb
mental illness.
bb bb
In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
alcohol daily and that he has noticed a tremor in his hands that affects his ability to
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
hold things. With this information, what response should the nurse make?
bb bb bb bb bb bb bb bb bb bb bb
A "Does the tremor change when you drink alcohol?"
bb bb bb bb bb bb bb bb
B "We'll do some tests to see what is causing the tremor."
bb bb bb bb bb bb bb bb bb bb bb
C "You really shouldn't drink so much alcohol; it may be causing your tremor."
bb bb bb bb bb bb bb bb bb bb bb bb bb
D "Does your family know you are drinking every day?" - ANSWER: A "Does the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
tremor change when you drink alcohol?"
bb bb bb bb bb bb
PRACTICE QUESTIONS NSG3160 AND
SOLUTIONS.
During a mental status assessment, which question by the nurse would best assess a
bb bb bb bb bb bb bb bb bb bb bb bb bb
person's judgment?
bb bb
A "Do you feel that you are being watched, followed, or controlled?"
bb bb bb bb bb bb bb bb bb bb bb
B "What would you do if you found a stamped, addressed envelope lying on the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
sidewalk?"
bb
C "What does the statement, 'People in glass houses shouldn't throw stones,' mean to
bb bb bb bb bb bb bb bb bb bb bb bb bb
you?"
bb
D "Tell me what you plan to do once you are discharged from the hospital." -
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
ANSWER: D "Tell me what you plan to do once you are discharged from the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
hospital."
bb
The nurse is conducting a patient interview. Which statement made by the patient
bb bb bb bb bb bb bb bb bb bb bb bb
should the nurse more fully explore to assess the mental status during the interview?
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
A "I have no health problems."
bb bb bb bb bb
B "I never did too good in school."
bb bb bb bb bb bb bb
C "I am not currently taking any medications."
bb bb bb bb bb bb bb
D "I sleep like a baby." - ANSWER: B "I never did too good in school."
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
During an examination, the nurse can assess mental status by which activity?
bb bb bb bb bb bb bb bb bb bb bb
A Observing the patient as he or she performs an intelligence quotient (IQ) test
bb bb bb bb bb bb bb bb bb bb bb bb bb
B Examining the patient's response to a specific set of questions
bb bb bb bb bb bb bb bb bb bb
C Observing the patient and inferring health or dysfunction
bb bb bb bb bb bb bb bb
D Examining the patient's electroencephalogram - ANSWER: C Observing the patient
bb bb bb bb bb bb bb bb bb bb
and inferring health or dysfunction
bb bb bb bb bb
,When taking the health history on a patient with a seizure disorder, the nurse
bb bb bb bb bb bb bb bb bb bb bb bb bb
assesses whether the patient has an aura. Which of these would be the best
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
question for obtaining this information?
bb bb bb bb bb
A "After the seizure, do you spend a lot of time sleeping?"
bb bb bb bb bb bb bb bb bb bb bb
B "Do you have any warning sign before your seizure starts?"
bb bb bb bb bb bb bb bb bb bb
C "Do you experience any color change or incontinence during the seizure?"
bb bb bb bb bb bb bb bb bb bb bb
D "Does your muscle tone seem tense or limp?" - ANSWER: B "Do you have any
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
warning sign before your seizure starts?
bb bb bb bb bb bb
During the assessment of an 80-year-old patient, the nurse notices that his hands
bb bb bb bb bb bb bb bb bb bb bb bb
show tremors when he reaches for something and his head is always nodding. No
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
associated rigidity is observed with movement. Which of these statements is most
bb bb bb bb bb bb bb bb bb bb bb bb
accurate?
bb
A These findings are normal, resulting from aging.
bb bb bb bb bb bb bb
B These findings could be r/t hyperthyroidism.
bb bb bb bb bb bb
C These findings are the result of Parkinson disease.
bb bb bb bb bb bb bb bb
D This patient should be evaluated for a cerebellar lesion. - ANSWER: A These
bb bb bb bb bb bb bb bb bb bb bb bb bb
findings are normal, resulting from aging.
bb bb bb bb bb bb
A man who was found wandering in a park at 2 AM has been brought to the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
emergency department for an examination; he said he fell and hit his head. During
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
the examination, the nurse asks him to use his index finger to touch the nurse's
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
finger, then his own nose, then the nurse's finger again (which has been moved to a
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
different location). The patient is clumsy, unable to follow the instructions, and
bb bb bb bb bb bb bb bb bb bb bb bb
overshoots the mark, missing the finger. What does the nurse suspect?
bb bb bb bb bb bb bb bb bb bb bb
A Cerebral injury
bb bb
B Peripheral neuropathy
bb bb
C Cerebrovascular accident
bb bb
D Acute alcohol intoxication - ANSWER: D Acute alcohol intoxication
bb bb bb bb bb bb bb bb bb
When assessing the intensity of a patient's pain, which question by the nurse is
bb bb bb bb bb bb bb bb bb bb bb bb bb
appropriate?
bb
A "How does pain limit your activities?"
bb bb bb bb bb bb
B "What does your pain feel like?"
bb bb bb bb bb bb
C "How much pain do you have now?"
bb bb bb bb bb bb bb
D "What makes your pain better or worse?" - ANSWER: C "How much pain do you
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
have now?"
bb bb
The nurse is teaching a class on pain at a local retirement community. Which
bb bb bb bb bb bb bb bb bb bb bb bb bb
statement about the pain experienced by older adults should the nurse include in the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
instructions?
bb
,A "Pain is a normal process of aging and is to be expected."
bb bb bb bb bb bb bb bb bb bb bb bb
B "Pain indicates a pathologic condition or an injury and is not a normal process of
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
aging."
bb
C "Older adults must learn to tolerate pain."
bb bb bb bb bb bb bb
D "Older individuals perceive pain to a lesser degree than do younger individuals." -
bb bb bb bb bb bb bb bb bb bb bb bb bb
ANSWER: B "Pain indicates a pathologic condition or an injury and is not a normal
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
process of aging."
bb bb bb
The nurse is conducting an interview with an adult male patient. Which statement
bb bb bb bb bb bb bb bb bb bb bb bb
made by the patient indicates an alcohol use disorder?
bb bb bb bb bb bb bb bb bb
A "I usually stay out longer and drink more than I intended but I still make it into work
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
on time."
bb bb
B "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
it."
bb
C "I have a strong urge to drink and I've tried to stop drinking several times but it
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
doesn't last long."
bb bb bb
D "I crave alcohol but have successfully cut down on my alcohol consumption." -
bb bb bb bb bb bb bb bb bb bb bb bb bb
ANSWER: C "I have a strong urge to drink and I've tried to stop drinking several
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
times but it doesn't last long."
bb bb bb bb bb bb
The nurse has completed an assessment on a patient who came to the clinic for a leg
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
injury. As a result of the assessment, the nurse has determined that the patient has
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
at-risk alcohol use. Which action by the nurse is most appropriate at this time?
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
A State, "You are drinking more than is medically safe. I strongly recommend that you
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
quit drinking, and I'm willing to help you."
bb bb bb bb bb bb bb bb
B Give the patient information about a local rehabilitation clinic.
bb bb bb bb bb bb bb bb bb
C Record the results of the assessment, and notify the physician on call.
bb bb bb bb bb bb bb bb bb bb bb bb
D State, "It appears that you may have a drinking problem. Here is the telephone
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
number of our local Alcoholics Anonymous chapter." - ANSWER: A State, "You are
bb bb bb bb bb bb bb bb bb bb bb bb bb
drinking more than is medically safe. I strongly recommend that you quit drinking, and
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
I'm willing to help you."
bb bb bb bb bb
During a mental status examination, the nurse wants to assess a patient's affect.
bb bb bb bb bb bb bb bb bb bb bb bb
Which question the nurse should ask?
bb bb bb bb bb bb
, A "Have these medications had any effect on your pain?"
bb bb bb bb bb bb bb bb bb
B "Would you please repeat the following words?"
bb bb bb bb bb bb bb
C "Has this pain affected your ability to get dressed by yourself?"
bb bb bb bb bb bb bb bb bb bb bb
D "How do you feel today?" - ANSWER: D "How do you feel today?"
bb bb bb bb bb bb bb bb bb bb bb bb bb
A woman brings her husband to the clinic for an examination. She is particularly
bb bb bb bb bb bb bb bb bb bb bb bb bb
worried because after a recent fall, he seems to have lost a great deal of his memory
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
of recent events. Which statement reflects the nurse's best course of action?
bb bb bb bb bb bb bb bb bb bb bb bb
A Plan to integrate the mental status examination into the history and physical
bb bb bb bb bb bb bb bb bb bb bb bb
examination.
bb
B Reassure his wife that memory loss after a physical shock is normal and will soon
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
subside.
bb
C Perform a complete mental status examination.
bb bb bb bb bb bb
D Refer him to a psychometrician. - ANSWER: C Perform a complete mental status
bb bb bb bb bb bb bb bb bb bb bb bb bb
examination.
bb
The nurse is providing instructions to a newly hired graduates for the mini-mental
bb bb bb bb bb bb bb bb bb bb bb bb
state examination (MMSE). Which statement best describes this examination?
bb bb bb bb bb bb bb bb bb
A The MMSE is a useful tool for an initial evaluation of mental status. Additional tools
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
are needed to evaluate cognition changes over time.
bb bb bb bb bb bb bb bb
B The MMSE is a good tool to evaluate mood and thought processes.
bb bb bb bb bb bb bb bb bb bb bb bb
C This examination is a good tool to detect delirium and dementia and to differentiate
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
these from psychiatric mental illness.
bb bb bb bb bb
D Scores below 30 indicate cognitive impairment. - ANSWER: C This examination is a
bb bb bb bb bb bb bb bb bb bb bb bb bb
good tool to detect delirium and dementia and to differentiate these from psychiatric
bb bb bb bb bb bb bb bb bb bb bb bb bb
mental illness.
bb bb
In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
alcohol daily and that he has noticed a tremor in his hands that affects his ability to
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
hold things. With this information, what response should the nurse make?
bb bb bb bb bb bb bb bb bb bb bb
A "Does the tremor change when you drink alcohol?"
bb bb bb bb bb bb bb bb
B "We'll do some tests to see what is causing the tremor."
bb bb bb bb bb bb bb bb bb bb bb
C "You really shouldn't drink so much alcohol; it may be causing your tremor."
bb bb bb bb bb bb bb bb bb bb bb bb bb
D "Does your family know you are drinking every day?" - ANSWER: A "Does the
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
tremor change when you drink alcohol?"
bb bb bb bb bb bb
