NUR 245 | NUR245 Exam 3: Health Assessment And
Promotion - MCPHS
1. A 52-year-old female visits the clinic for a routine check-up and asks about breast cancer
screening guidelines. Which instruction should the nurse provide based on evidence-based
health promotion strategies?
A. Annual mammograms are recommended starting at age 45 for women with average risk.
B. Breast self-exams should be performed daily to identify small nodules.
C. Clinical breast exams are no longer necessary if the patient is asymptomatic.
D. Mammography is only required every five years after the age of 50.
Correct Answer: A
Rationale: Current American Cancer Society guidelines suggest women aged 45 to 54
should get mammograms every year. For women aged 40 to 44, the option to start annual
screening should be available if they choose. Breast self-exams are encouraged for
awareness rather than daily diagnostic checks. Early detection through regular screening
significantly improves outcomes in breast cancer treatment. Providing clear information
helps patients make informed decisions about their preventive healthcare.
2. When performing a testicular health assessment on a 22-year-old male, which statement
by the nurse best promotes effective health maintenance?
A. Testicular cancer is most common in men over the age of 60.
B. Report any lumps only if they become painful or cause redness.
C. Perform a self-exam monthly in a warm shower to relax the scrotal skin.
D. Testicular exams are only necessary if you have a family history of the disease.
Correct Answer: C
Rationale: Testicular self-examination is critical because testicular cancer is the most
common cancer in young men aged 15 to 35. Performing the exam in a warm shower
allows the scrotum to relax, making it easier to feel for abnormalities. The nurse should
emphasize that the exam is performed monthly to establish a baseline of what is normal.
Pain is not always a symptom of cancer, so any firm lump should be reported immediately.
This education empowers the patient to take a proactive role in his own health monitoring.
3. A nurse is calculating the Body Mass Index (BMI) for a patient and determines the value is
28.5 kg/m². How should the nurse interpret and communicate this finding during a lifestyle
risk assessment?
A. The patient is within the healthy weight range for their height.
B. The patient is classified as overweight and is at increased risk for chronic diseases.
,C. The patient is classified as underweight and needs nutritional support.
D. The patient is classified as obese and requires immediate surgical intervention.
Correct Answer: B
Rationale: A BMI between 25 and 29.9 is medically classified as overweight, while a range
of 18.5 to 24.9 is considered healthy. This classification serves as a screening tool to
identify potential health risks such as hypertension and type 2 diabetes. The nurse must
communicate this result sensitivity while focusing on health promotion and lifestyle
modifications. BMI does not measure body fat directly but is a useful indicator for overall
health risk populations. Education should include discussing balanced nutrition and
increased physical activity to manage weight effectively.
4. During a skin assessment, the nurse notes a lesion on the patient’s shoulder. Which
‘ABCDE’ characteristic would most strongly suggest a need for further evaluation for
melanoma?
A. Symmetry in shape with a single, uniform tan color.
B. Evolution or change in the size, shape, or color of the lesion.
C. Smooth, well-defined borders that are easy to trace.
D. A diameter of less than 2 millimeters.
Correct Answer: B
Rationale: The ‘E’ in the ABCDE mnemonic stands for evolution, which refers to any
change in a mole over time. Changes in size, color, or shape are significant red flags for
malignant melanoma. A represents asymmetry, B represents irregular borders, C
represents multiple colors, and D represents a diameter larger than 6mm. Regular skin self-
assessments are promoted to detect these changes at an early, treatable stage. The nurse
should document any suspicious findings and refer the patient to a dermatologist for a
biopsy.
5. An 80-year-old patient is being assessed for fall risk in the home. Which environmental
factor identified by the nurse represents the highest risk for this population?
A. The presence of grab bars in the bathroom and shower area.
B. Adequate lighting in the stairwells and entryways.
C. Throw rugs placed on the hardwood floors in the hallways.
D. The use of a non-slip mat inside the bathtub.
Correct Answer: C
Rationale: Throw rugs are a major environmental hazard for older adults as they can
easily cause trips and slips. Fall prevention is a primary health promotion goal for the
elderly to maintain independence and prevent fractures. The nurse’s role includes
, identifying these hazards and suggesting modifications like removing rugs or securing
them with tape. Other important factors include ensuring bright lighting and installing
assistive devices like handrails. A comprehensive home safety assessment is vital for
reducing injury-related morbidity in the geriatric population.
6. A nurse is conducting a health interview with a patient from a different cultural
background. To ensure culturally competent care, which action should the nurse take first?
A. Assume the patient follows all traditional health practices of their culture.
B. Perform a self-assessment of one’s own cultural biases and beliefs.
C. Use the patient’s family members as the primary interpreters for medical information.
D. Limit the assessment to physical symptoms to avoid cultural conflict.
Correct Answer: B
Rationale: Cultural competence begins with self-awareness of the nurse’s own values and
potential biases. By understanding one’s own perspective, the nurse can better approach
the patient with an open and non-judgmental mindset. Using family members as
interpreters is discouraged because it can lead to confidentiality issues and clinical
inaccuracies. Each patient should be treated as an individual rather than a stereotype of
their cultural group. This foundational step ensures that health promotion strategies are
tailored to the patient’s unique needs and values.
7. A patient expresses interest in quitting smoking. According to the Transtheoretical Model
(Stages of Change), the patient is in the ‘Preparation’ stage. Which nursing intervention is
most appropriate?
A. Educate the patient on the long-term dangers of tobacco use.
B. Congratulate the patient on maintaining a smoke-free life for six months.
C. Wait for the patient to bring up the topic again in future visits.
D. Help the patient develop a specific plan and set a ‘quit date’.
Correct Answer: D
Rationale: In the preparation stage, the individual intends to take action in the immediate
future and may have already taken some small steps. The nurse should support this by
helping the patient create a concrete action plan and identifying resources. Providing
education on dangers is more suitable for the pre-contemplation or contemplation stages.
Maintenance interventions are reserved for those who have already successfully quit for a
period of time. Effective nursing care aligns the intervention with the patient’s current level
of readiness to change.
8. A 65-year-old postmenopausal woman is being screened for osteoporosis. Which risk
factor identified during the assessment should the nurse prioritize for education?
A. A history of smoking and a sedentary lifestyle.
Promotion - MCPHS
1. A 52-year-old female visits the clinic for a routine check-up and asks about breast cancer
screening guidelines. Which instruction should the nurse provide based on evidence-based
health promotion strategies?
A. Annual mammograms are recommended starting at age 45 for women with average risk.
B. Breast self-exams should be performed daily to identify small nodules.
C. Clinical breast exams are no longer necessary if the patient is asymptomatic.
D. Mammography is only required every five years after the age of 50.
Correct Answer: A
Rationale: Current American Cancer Society guidelines suggest women aged 45 to 54
should get mammograms every year. For women aged 40 to 44, the option to start annual
screening should be available if they choose. Breast self-exams are encouraged for
awareness rather than daily diagnostic checks. Early detection through regular screening
significantly improves outcomes in breast cancer treatment. Providing clear information
helps patients make informed decisions about their preventive healthcare.
2. When performing a testicular health assessment on a 22-year-old male, which statement
by the nurse best promotes effective health maintenance?
A. Testicular cancer is most common in men over the age of 60.
B. Report any lumps only if they become painful or cause redness.
C. Perform a self-exam monthly in a warm shower to relax the scrotal skin.
D. Testicular exams are only necessary if you have a family history of the disease.
Correct Answer: C
Rationale: Testicular self-examination is critical because testicular cancer is the most
common cancer in young men aged 15 to 35. Performing the exam in a warm shower
allows the scrotum to relax, making it easier to feel for abnormalities. The nurse should
emphasize that the exam is performed monthly to establish a baseline of what is normal.
Pain is not always a symptom of cancer, so any firm lump should be reported immediately.
This education empowers the patient to take a proactive role in his own health monitoring.
3. A nurse is calculating the Body Mass Index (BMI) for a patient and determines the value is
28.5 kg/m². How should the nurse interpret and communicate this finding during a lifestyle
risk assessment?
A. The patient is within the healthy weight range for their height.
B. The patient is classified as overweight and is at increased risk for chronic diseases.
,C. The patient is classified as underweight and needs nutritional support.
D. The patient is classified as obese and requires immediate surgical intervention.
Correct Answer: B
Rationale: A BMI between 25 and 29.9 is medically classified as overweight, while a range
of 18.5 to 24.9 is considered healthy. This classification serves as a screening tool to
identify potential health risks such as hypertension and type 2 diabetes. The nurse must
communicate this result sensitivity while focusing on health promotion and lifestyle
modifications. BMI does not measure body fat directly but is a useful indicator for overall
health risk populations. Education should include discussing balanced nutrition and
increased physical activity to manage weight effectively.
4. During a skin assessment, the nurse notes a lesion on the patient’s shoulder. Which
‘ABCDE’ characteristic would most strongly suggest a need for further evaluation for
melanoma?
A. Symmetry in shape with a single, uniform tan color.
B. Evolution or change in the size, shape, or color of the lesion.
C. Smooth, well-defined borders that are easy to trace.
D. A diameter of less than 2 millimeters.
Correct Answer: B
Rationale: The ‘E’ in the ABCDE mnemonic stands for evolution, which refers to any
change in a mole over time. Changes in size, color, or shape are significant red flags for
malignant melanoma. A represents asymmetry, B represents irregular borders, C
represents multiple colors, and D represents a diameter larger than 6mm. Regular skin self-
assessments are promoted to detect these changes at an early, treatable stage. The nurse
should document any suspicious findings and refer the patient to a dermatologist for a
biopsy.
5. An 80-year-old patient is being assessed for fall risk in the home. Which environmental
factor identified by the nurse represents the highest risk for this population?
A. The presence of grab bars in the bathroom and shower area.
B. Adequate lighting in the stairwells and entryways.
C. Throw rugs placed on the hardwood floors in the hallways.
D. The use of a non-slip mat inside the bathtub.
Correct Answer: C
Rationale: Throw rugs are a major environmental hazard for older adults as they can
easily cause trips and slips. Fall prevention is a primary health promotion goal for the
elderly to maintain independence and prevent fractures. The nurse’s role includes
, identifying these hazards and suggesting modifications like removing rugs or securing
them with tape. Other important factors include ensuring bright lighting and installing
assistive devices like handrails. A comprehensive home safety assessment is vital for
reducing injury-related morbidity in the geriatric population.
6. A nurse is conducting a health interview with a patient from a different cultural
background. To ensure culturally competent care, which action should the nurse take first?
A. Assume the patient follows all traditional health practices of their culture.
B. Perform a self-assessment of one’s own cultural biases and beliefs.
C. Use the patient’s family members as the primary interpreters for medical information.
D. Limit the assessment to physical symptoms to avoid cultural conflict.
Correct Answer: B
Rationale: Cultural competence begins with self-awareness of the nurse’s own values and
potential biases. By understanding one’s own perspective, the nurse can better approach
the patient with an open and non-judgmental mindset. Using family members as
interpreters is discouraged because it can lead to confidentiality issues and clinical
inaccuracies. Each patient should be treated as an individual rather than a stereotype of
their cultural group. This foundational step ensures that health promotion strategies are
tailored to the patient’s unique needs and values.
7. A patient expresses interest in quitting smoking. According to the Transtheoretical Model
(Stages of Change), the patient is in the ‘Preparation’ stage. Which nursing intervention is
most appropriate?
A. Educate the patient on the long-term dangers of tobacco use.
B. Congratulate the patient on maintaining a smoke-free life for six months.
C. Wait for the patient to bring up the topic again in future visits.
D. Help the patient develop a specific plan and set a ‘quit date’.
Correct Answer: D
Rationale: In the preparation stage, the individual intends to take action in the immediate
future and may have already taken some small steps. The nurse should support this by
helping the patient create a concrete action plan and identifying resources. Providing
education on dangers is more suitable for the pre-contemplation or contemplation stages.
Maintenance interventions are reserved for those who have already successfully quit for a
period of time. Effective nursing care aligns the intervention with the patient’s current level
of readiness to change.
8. A 65-year-old postmenopausal woman is being screened for osteoporosis. Which risk
factor identified during the assessment should the nurse prioritize for education?
A. A history of smoking and a sedentary lifestyle.
