Fundamentals of Nursing NCLEX Practice Questions Quiz Set 6 | 75 Questions| 2022 update with rationales

Fundamentals of Nursing NCLEX Practice Questions Quiz Set 6 | 75 Questions 1. 1. Question The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client? o A. Arranging for the wheelchair o B. Asking her family to visit o C. Assisting her to sit out of bed in a chair qid o D. Encouraging the use of an overhead trapeze Incorrect Correct Answer: D. Encouraging the use of an overhead trapeze. Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Facilitates movement during hygiene or skincare and linen changes; reduces the discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed. • Option A: Sitting in a wheelchair would require too great hip flexion initially. Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. Reduces the risk of flexion contracture of the hip. • Option B: Asking her family to visit would not facilitate the resumption of activities. Provide footboard, wrist splints, trochanter, or hand rolls as appropriate. Useful in maintaining a functional position of extremities, hands, and feet, and preventing complications (contractures, foot drop). • Option C: Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker. Encourage the use of isometric exercises starting with the unaffected limb. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema are present. 2. 2. Question Which of the following is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding? • A. Measure intake and output • B. Check albumin level • C. Monitor glucose levels • D. Increase enteral feeding Incorrect Correct Answer: A. Measure intake and output It is important to measure intake and output, which should be equal. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance. A urinary catheter is inserted to assess the adequacy of renal perfusion. The kidney requires 20% to 25% of cardiac output; commonly, it’s the first organ to show the effects of impaired perfusion or intravascular volume. • Option B: Osmotherapy aims to increase the osmolality of the intravascular space, which in turn helps mobilize excess fluid from brain tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to decrease cerebral edema, transiently increase intravascular volume, and improve cerebral blood flow. • Option C: Low peripheral oxygen saturation values or low arterial blood oxygen values (as shown by arterial blood gas testing) should be avoided. Maintaining adequate brain tissue oxygenation seems to improve patient outcomes. • Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed. Initially, a nasogastric or orogastric tube is inserted to decompress the stomach and reduce the aspiration risk. (Typically, the nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis or VAP). 3. 3. Question The pathological process causing esophageal varices is/are: • A. Ascites and edema • B. Systemic hypertension • C. Portal hypertension • D. Dilated veins and varicosities Incorrect Correct Answer: C. Portal hypertension Esophageal varices result from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will backflow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids. • Option A: Portal hypertension causes portocaval anastomosis to develop to decompress portal circulation. Normal portal pressure is between 5-10 mmHg but in the presence of portal obstruction, the pressure may be as high as 15-20 mmHg. Since the portal venous system has no valves, resistance at any level between the splanchnic vessels and the right side of the heart results in retrograde flow and elevated pressure. • Option B: Esophageal varices are dilated submucosal distal esophageal veins connecting the portal and systemic circulations. They form due to portal hypertension, which commonly is a result of cirrhosis, resistance to portal blood flow, and increased portal venous blood inflow. • Option D: Intrahepatic vasoconstriction due to decreased nitric oxide production, and increased release of endothelin-1 (ET-1), angiotensinogen, and eicosanoids. Increased portal flow is caused by hyperdynamic circulation due to splanchnic arterial vasodilation through mediators such as nitric oxide, prostacyclin, and TNF. 4. 4. Question Which of the following interventions will help lessen the effect of GERD (acid reflux)? • A. Elevate the head of the bed on 4-6 inch blocks. • B. Lie down after eating. • C. Increase fluid intake just before bedtime. • D. Wear a girdle. Incorrect Correct Answer: A. Elevate the head of the bed on 4-6 inch blocks. Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. The fluid does not flow uphill. Instruct to remain in an upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime. Helps control reflux and causes less irritation from reflux action into the esophagus. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure. • Option B: Avoid placing the patient in a supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. Elevate HOB while in bed. To prevent aspiration by preventing the gastric acid to flow back into the esophagus. • Option C: Instruct patient regarding eating small amounts of bland food followed by a small amount of water. Instruct to remain in an upright position at least 1–2 hours after meals, and to avoid eating within 2–4 hours of bedtime. Gravity helps control reflux and causes less irritation from reflux action into the esophagus. • Option D: Instruct the patient to avoid bending over, coughing, straining at defecations, and other activities that increase reflux. Promotes comfort by the decrease in intra-abdominal pressure, which reduces the reflux of gastric contents. 5. 5. Question The main benefit of therapeutic massages is: • A. To help a person with swollen legs to decrease fluid retention. • B. To help a person with duodenal ulcers feel better. • C. To help damaged tissue in a diabetic to heal. • D. To improve circulation and muscle tone. Incorrect Correct Answer: D. To improve circulation and muscle tone. Particularly in elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. Damaged or strained muscle fibers release inflammatory chemicals to aid the healing process, but these chemicals cause significant pain and discomfort in the process. At least one study, which looked at the effects of massage on post-exercise tissue inflammation, suggests that even 10 minutes of massage can reduce signs of inflammation and improve cell processes, thereby promoting healing, with effects lasting several hours after the massage. • Option A: Massage only the hands, feet, or scalp of patients with sepsis, fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia, or meningitis. • Option B: When patients have fragile skin, or the potential for skin breakdown, apply only light pressure, using enough lotion or oil to minimize friction. For patients with a previous injury, chronic pain, or scar tissue, frequently ask them how the massage feels, and adjust both pressure and massage technique to the patients’ preferences. • Option C: A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot. Although massage is associated with few adverse effects, nurses should be careful to avoid areas near open wounds, any stage of pressure ulcer, reddened or swollen areas, rashes, incisions, thromboses, iv lines, drains, shunts, and tubes. 6. 6. Question Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)? • A. Lettuce • B. Eggs • C. Chocolate • D. Butterscotch Incorrect Correct Answer: C. Chocolate Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a surge of serotonin. This surge can cause the esophageal sphincter to relax and gastric contents to rise. Caffeine and theobromine in chocolate may also trigger acid reflux. All of the other foods do not affect LES pressure. • Option A: Vegetables are naturally low in fat and sugar, and they help reduce stomach acid. Good options include green beans, broccoli, asparagus, cauliflower, leafy greens, potatoes, and cucumbers. • Option B: Egg whites are a good option. Stay away from egg yolks, though, which are high in fat and may trigger reflux symptoms. Reflux symptoms may result from stomach acid touching the esophagus and causing irritation and pain. • Option D: The foods the patient eats affect the amount of acid the stomach produces. Eating the right kinds of food is key to controlling acid reflux or GERD, a severe, chronic form of acid reflux. Sources of healthy fats include avocados, walnuts, flaxseed, olive oil, sesame oil, and sunflower oil. Reduce the intake of saturated fats and trans fats and replace them with these healthier unsaturated fats. 7. 7. Question Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)? • A. Withhold medications while the TPN is infusing. • B. Change TPN solution every 24 hours. • C. Flush the TPN line with water prior to initiating nutritional support. • D. Keep the client on complete bed rest during TPN therapy. Incorrect Correct Answer: B. Change TPN solution every 24 hours. TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to the hypertonicity of the solution. Because the central venous catheter needs to remain in place for a long time, a strict sterile technique must be used during the insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques. • Option A: Medication therapy can continue during TPN therapy. Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often. • Option C: Flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skincare around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates. • Option D: However, other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest. Place the client in a semi-Fowler’s or high-Fowler’s position. Maintaining the head of the bed elevated will promote ease in breathing. This position also allows the pooling of fluid in the bases and for gas exchange to be more available to the lung tissue. 8. 8. Question Which of the following should be included in a plan of care for a client who is lactose intolerant? • A. Remove all dairy products from the diet. • B. Frozen yogurt can be included in the diet. • C. Drink small amounts of milk on an empty stomach. • D. Spread out selection of dairy products throughout the day. Incorrect Correct Answer: B. Frozen yogurt can be included in the diet. Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Some people who are lactose-intolerant can eat some kinds of yogurt without problems, especially yogurt with live cultures. • Option A: Elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Be sure to get enough calcium in the diet, especially if the client avoids milk products completely. To get enough calcium, the client would need to eat calcium-rich foods as often as someone would drink milk. Calcium is very important because it keeps bones strong and reduces the risk of osteoporosis. • Option C: Drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat) may decrease transit time and allow for increased lactase activity. Limit the amount of milk and milk products in the diet. Try to drink 1 glass of milk each day. Drink small amounts several times a day. All types of milk contain the same amount of lactose. Option D: Although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms. Eat or drink milk and milk products along with other foods. For some people, combining solid food (like cereal) with a dairy product (like milk) can reduce symptoms. 9. 9. Question Pain tolerance in an elderly patient with cancer would: • A. Stay the same. • B. Be lowered. • C. Be increased. • D. No effect on pain tolerance. Incorrect Correct Answer: B. Be lowered. There is potential for a lowered pain tolerance to exist with diminished adaptive capacity. For older patients with cancer, unrelieved pain can affect functioning, increase cognitive impairment, and depression, which in turn can influence the severity of pain and make management more challenging. In sum, the literature indicates that cancer pain in advanced disease is multifaceted and can adversely affect the lives of patients and their caregivers. Changes associated with aging have the potential to further impact this experience. • Option A: Pain continues to be a common and distressing symptom, despite pain management being a central focus of palliative care and guidelines for the management of cancer pain. Estimates suggest that as many as 60% to 80% of individuals with recurrent or metastatic cancer experience pain. Among older patients, cancer pain, similar to other types of pain, tends to go unrecognized and undertreated • Option C: In older individuals, the higher incidence of comorbidities, age-related declines in functioning, and associated symptoms can further complicate cancer pain and its management. Adding to the complexity is the recognition that the experience of pain is not merely a sensory event, but is multifaceted, comprising sensory, affective, and evaluative components. • Option D: Indeed, the belief that pain can emanate from both physical sources and nonphysical sources (psychological, spiritual, and interpersonal) is central to the concept of total pain, put forth by Dame Cicely Saunders, founder of the modern hospice. This nonphysical source of pain derives from feelings of helplessness, being dependent on others, and having difficulty in reshaping relationships, and has been described by terminally ill older patients as creating the worst suffering. 10. 10. Question What is the main advantage of cutaneous stimulation in managing pain? • A. Costs less. • B. Restricts movement and decreases. • C. Gives client control over pain syndrome. • D. Allows the family to care for the patient at home. Incorrect Correct Answer: C. Gives client control over pain syndrome. Cutaneous stimulation allows the patient to have control over his pain and allows him to be in his own environment. Cutaneous stimulation increases movement and decreases pain. Cutaneous stimulation involves stimulation of nerves via skin contact in an effort to reduce pain impulses to the brain, based on the “gate control” theory of pain. A device used to provide electrocutaneous nerve stimulation was studied for its effect on symptoms of peripheral neuropathy. • Option A: The potential for TENS-associated improvement, combined with reduced medication-related complications and costs, are important points that clinicians should consider when constructing a treatment plan for chronic pain patients. Finally, cost simulation techniques provide a useful tool for assessing outcomes in pain treatment and research. • Option B: CS effectively reduces pain, heart rate, and blood pressure in ED patients. The intervention of CS has solid utilization potential and could be easily incorporated into standard ED procedures. • Option D: TENS devices can be purchased over the counter and without medical prescription in the UK. However, a practitioner experienced in TENS principles should supervise patients using TENS for the first time. A point of contact to troubleshoot any problems should also be provided. 11. 11. Question The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to • A. Exercise doing weight-bearing activities. • B. Exercise to reduce weight. • C. Avoid exercise activities that increase the risk of fracture. • D. Exercise to strengthen muscles and thereby protect bones. Incorrect Correct Answer: A. Exercise doing weight-bearing activities. Weight-bearing exercises are beneficial in the treatment of osteoporosis. Although the loss of bone cannot be substantially reversed, it can be greatly reduced if the client includes weight-bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol. 45 minutes to one hour of aerobic activity two to three times per week • Option B: Resistance training two or three times per week. Each session should include exercises to strengthen the lower limb, trunk, and arm muscles, and each exercise should be performed eight to 10 times • Option C: Balance exercises need to be at a level that is challenging to balance and should be performed for a few minutes at least twice a week. For safety reasons, always make sure to hold on to something if you overbalance it. People with severe osteoporosis or kyphosis (hunching of the upper back) who are at high risk of bone fractures may find that swimming or water exercise is their preferred activity. • Option D: Even though walking is a weight-bearing exercise, it does not greatly improve bone health, muscle strength, fitness or balance, unless it is carried out at high intensity such as at a faster pace, for long durations (such as bushwalking), or incorporates challenging terrain such as hills. 12. 12. Question A client in a long-term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to • A. Have the client identify coping methods. • B. Get the description of the location and intensity of the pain. • C. Accept the client’s report of pain. • D. Determine the client’s status of pain. Incorrect Correct Answer: C. Accept the client’s report of pain. Although all of the options above are correct, the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain –“the client’s report.” Pain is the most common complaint seen in a primary care office. There are over 50 million Americans, 20 percent of all patients, that suffer from chronic pain in the United States. • Option A: Effective treatment modalities for acute, chronic, centralized, or neuropathic are often different. Ten percent of the United States population complain of neuropathic pain. This population may benefit from a serotonin-norepinephrine reuptake inhibitor (SNRI) such as duloxetine, as compared to ibuprofen for an acute injury. • Option B: To fully assess the location of a patient’s pain, a body diagram map can be completed. Ankle sprains are solitary, acute injuries. Body diagrams may not be necessary in such a case. Localized pain is different from whole-body pain. Yet, in a patient with multiple comorbid pain disorders such as fibromyalgia, centralized pain disorder, and rheumatoid arthritis, distinguishing between the numerous locations of a patient’s pain, as well as factoring in the radiation of their pain, is difficult. • Option D: An essential first step in the pain assessment is distinguishing nociceptive pain from neuropathic. Pain characterized as burning, shooting, pins, and needles, or electric shock-like point the differential towards a neuropathic origin of the patient’s pain Sharp or throbbing pain is more likely to be acute nociceptive pain. 13. 13. Question Which statement best describes the effects of immobility in children? • A. Immobility prevents the progression of language and fine motor development. • B. Immobility in children has similar physical effects to those found in adults. • C. Children are more susceptible to the effects of immobility than are adults. • D. Children are likely to have prolonged immobility with subsequent complications. Incorrect Correct Answer: B. Immobility in children has similar physical effects to those found in adults. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults. • Option A: The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, decreased cardiac reserve, edema, emboli, thrombophlebitis, constipation and the loss of calcium from the bones, are highly costly in terms of health care dollars and in terms of client suffering. • Option C: Immobility and complete bed rest can lead to life-threatening physical and psychological complications and consequences. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. Immobility can adversely affect all physiological bodily systems. • Option D: Children stayed in a cast for a long period, so that the effect of postoperative immobility had negative effects on the physical and psychological wellbeing of children with musculoskeletal injuries. Emphasize the importance of implementing a nursing care program for children in the postoperative period for minimizing the physical and psychological effects of immobility on children with musculoskeletal injuries. 14. 14. Question After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest? • A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk. • B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. • C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice. • D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Incorrect Correct Answer: D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats. Eat a Mediterranean?style diet—more bread, fruit, vegetables, and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils (reduces total mortality and the risk of myocardial infarction). • Option A: Consume at least 7?g of omega?3 fatty acids per week from 2–4 portions of oily fish per week. If within 3?months of myocardial infarction and they are not achieving this, consider providing at least 1?g daily of omega?3?acid ethyl esters treatment licensed for secondary prevention after myocardial infarction for up to 4 years. • Option B: Choose foods with less sodium and prepare foods with little or no salt. To lower blood pressure, aim to eat no more than 2,300 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further. • Option C: Processed meats, like hot dogs, sausage, and lunch meat, are loaded with sodium and nitrates. This can raise the blood pressure and the risk of another heart attack. High blood pressure is particularly dangerous because there usually aren’t any symptoms. 15. 15. Question A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers? • A. A 79-year-old malnourished client on bed rest. • B. An obese client who uses a wheelchair. • C. An incontinent client who has had 3 diarrhea stools. • D. An 80-year-old ambulatory diabetic client. Incorrect Correct Answer: A. A 79-year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubitus, due in part to poor hydration and inadequate protein intake. Both external and internal factors work simultaneously, forming these ulcers. External factors; pressure, friction, shear force, and moisture and internal factors; fever, malnutrition, anemia, and endothelial dysfunction speed up the process of these lesions. • Option B: Immobility of as little as two hours in a bedridden patient or patient undergoing surgery is sufficient to create the basis of a decubitus ulcer. The dysfunction of nervous regulatory mechanisms responsible for the regulation of local blood flow is somewhat culpable in the formation of these ulcers. Prolonged pressure on tissues can cause capillary bed occlusion and, thus, low oxygen levels in the area. Over time, the ischemic tissue begins to accumulate toxic metabolites. Subsequently, tissue ulceration and necrosis occur. • Option C: The development of decubitus ulcers is complex and multifactorial. Loss of sensory perception, locally and general impaired loss of consciousness, along with decreased mobility, are the most important causes that aid in the formation of these ulcers because patients are not aware of discomfort hence do not relieve the pressure. • Option D: Elderly patients are more prone to sacral decubitus ulcers; two-thirds of ulcers occur in patients who are over 70 years old. There is data that shows 83% of hospitalized patients with ulcers developed them within five days of their hospitalization. 16. 16. Question Mrs. Kennedy had a CVA (cerebrovascular accident) and has a severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects the correct use of the cane? • A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg. • her left leg. B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg. • C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward then moves her left leg forward. • D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves her right leg forward. Incorrect Correct Answer: A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Mrs. Kennedy. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg. • Option B: She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. To go upstairs, use the handrail and step up with the unaffected leg first and follow with the cane and the affected foot together. • Option C: The cane should be held in the left hand, the hand opposite the affected leg. Hold the cane in the hand of the unaffected side. Move the cane and the affected leg forward at the same time, so that the cane helps take the weight of the weak leg. Then step with the unaffected leg. • Option D: If Mrs. Kennedy. moved the cane and her strong foot at the same time, she would be left standing on her weak leg at one point. This would be unstable at best; at worst, impossible. To go downstairs, use the handrail and step down with the affected foot and cane together first and follow with the unaffected foot. 17. 17. Question The nurse is instructing a woman on a low-fat, high-fiber diet. Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet? • A. Tuna salad sandwich on whole-wheat bread. • B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread. • C. Chef’s salad with hard-boiled eggs and fat-free dressing. • D. Broiled chicken stuffed with chopped apples and walnuts. Incorrect Correct Answer: B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread. This choice shows a low-fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes). Eating a high-fiber diet that is low in fat can help maintain overall health. Fiber-rich foods are naturally low in fat and contain cancer-fighting and heart-healthy properties. While a low-fat diet is good, it is important that the client does not dismiss all fats, however. Eat some foods containing unsaturated fats because they are necessary for an overall healthy diet. • Option A: Mayonnaise in tuna salad is high in fat. The whole-wheat bread has some fiber. Fiber’s presence in the digestive tract can help reduce the body’s cholesterol absorption. This is especially true if you take statins, which are medications to lower cholesterol, and use fiber supplements like psyllium fiber • Option C: Salad is high in fiber, but hard-boiled eggs are high in fat. In fact, a single egg contains 212 mg of cholesterol, which is 71% of the recommended daily intake. Plus, 62% of the calories in whole eggs are from fat. • Option D: There is some fiber in the apples and walnuts. The walnuts are high in fat, as is the chicken. Nuts have a high-fat content, so are high in energy. In most nuts, this is mainly unsaturated fat: either polyunsaturated fats in walnuts and pine nuts or monounsaturated fats in almonds, pistachios, pecans, and hazelnuts, for example. Brazil nuts, cashews, and macadamia nuts are higher in saturated fat. 18. 18. Question An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility? • A. Stiffness of the right ankle joint. • B. Soreness of the gums. • C. Short-term memory loss. • D. Decreased appetite. Incorrect Correct Answer: A. Stiffness of the right ankle joint. Stiffness of a joint may indicate the beginning of contracture and/or early muscle atrophy. In the development of joint contractures that result from long-term immobilization, shortening of the joint capsule, synovial adhesions and arthrofibrosis play decisive roles and may present as a generalized joint stiffness • Option B: Soreness of the gums is not related to immobility. Brushing too hard, improper flossing techniques, infection, or gum disease can cause sore and sensitive gums. Other causes unrelated to oral hygiene could include Vitamin K deficiency, hormonal changes during pregnancy, leukemia, or blood disorders. • Option C: Short-term memory loss is not related to immobility. Short-term memory loss is when one forgets things they heard, saw, or did recently. It’s a normal part of getting older for many people. But it can also be a sign of a deeper problem, such as dementia, a brain injury, or a mental health issue. • Option D: Decreased appetite is unlikely to be related to immobility. People can experience a loss of appetite for a wide range of reasons. Some of these are short-term, including colds, food poisoning, other infections, or the side effects of medication. Others are to do with long-term medical conditions, such as diabetes, cancer, or life-limiting illnesses. 19. 19. Question An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron-deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents? • A. Normal dietary intake. • B. Relevant socio-cultural, economic, and educational background of the family. • C. Any evidence of blood in the stools. • D. A history of maternal anemia during pregnancy. Incorrect Correct Answer: A. Normal dietary intake. Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to 5 months of infancy iron stores laid down for the baby during pregnancy are adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk, which contains no iron, and does not receive adequate dietary iron or supplemental iron. • Option B: Daily dietary intake is much more related to the diagnosis of iron deficiency anemia than is the socio-cultural, economic, and educational background of the family. The cause of iron-deficiency anemia varies based on age, gender, and socioeconomic status. Iron deficiency may result from insufficient iron intake, decreased absorption, or blood loss. • Option C: Iron deficiency anemia in an infant is very unlikely to be related to gastrointestinal bleeding. In developing countries, a parasitic infestation is also a significant cause of iron deficiency anemia. Dietary sources of iron are green vegetables, red meat, and iron-fortified milk formulas. • Option D: Anemia during pregnancy is unlikely to be the cause of the infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is anemic. In neonates, breastfeeding is protective against iron deficiency due to the higher bioavailability of iron in breast milk compared to cow’s milk; iron deficiency anemia is the most common form of anemia in young children on cow’s milk. 20. 20. Question A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse? • A. The client’s dietary habits include foods high in bulk. • B. The client’s fluid intake is between ml per day. • C. The client engages in moderate exercise each day. • D. The client’s bowel habits were not discussed. Incorrect Correct Answer: D. The client’s bowel habits were not discussed. To assess the client for a bowel training program the factors causing the bowel alteration should be assessed. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. • Option A: Foods high in bulk are appropriate. Assist the patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetables, whole grains) per day. Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged. • Option B: The client and the family should assist in the planning of the program which should include foods high in bulk, adequate exercise, and fluid intake of ml. Encourage the patient to take in fluid 2000 to 3000 mL/day, if not contraindicated medically. Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake. • Option C: Exercise should be a part of a bowel training regimen. Urge the patient for some physical activity and exercise. Consider isometric abdominal and gluteal exercises. Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation. 21. 21. Question Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient? • A. Alert and oriented to date, time, and place. • B. Buccal cyanosis and capillary refill greater than 3 seconds. • C. Clear breath sounds and nonproductive cough. • D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3. Incorrect Correct Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds. Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data. • Option A: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation and may require further intervention. Check pulse oximetry results with any mental status changes in older adults. • Option C: Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction. • Option D: Monitor serial chest x-rays, ABGs, pulse oximetry readings. Follows progress and effects and extent of pneumonia. Therapeutic regimen, and may facilitate necessary alterations in therapy. Oxygen saturation should be maintained at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue. 22. 22. Question During the nursing assessment, which data represent information concerning health beliefs? • A. Family role and relationship patterns. • B. Educational level and financial status. • C. Promotive, preventive, and restorative health practices. • D. Use of prescribed and over-the-counter medications. Incorrect Correct Answer: C. Promotive, preventive, and restorative health practices. The health-beliefs assessment includes expectations of health care; promotive, preventive, and restorative practices, such as breast self-examination, testicular examination, and seat-belt use; and how the client perceives illness. The basic premise of the health belief assessment is that patients have a right to their cultural beliefs, values, and practices, and that these factors should be understood, respected, and considered when giving culturally competent care. • Option A: Educational level and financial status represent information associated with role and relationship patterns. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual’s unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. • Option B: Family role and relationship patterns represent information associated with role and relationship patterns. The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. • Option D: The use of medications provides information about the client’s personal habits. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition-appropriate pain scale. The assessment identifies the current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care. 23. 23. Question Nurse Patrick is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history? • A. The chief complaint • B. Past health status • C. History immunizations • D. Location of an advance directive Incorrect Correct Answer: D. Location of an advance directive Biographic information may include name, address, gender, race, occupation, and location of a living will or durable power of attorney for health care. Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client’s birth date, Social Security number, medical record number, or similar identifying data may be included in the biographic data section. The chief complaint, past health status, and history of immunizations are part of assessing the client’s health and illness patterns. • Option A: Encourage the client to explain the health problem or symptom in as much detail as possible by focusing on the onset, progression, and duration of the problem; signs and symptoms and related problems; and what the client perceives as causing the problem. The client’s answers to the questions provide the nurse with a great deal of information about the client’s problem and especially how it affects the lifestyle and activities of daily living. This helps the nurse to evaluate the client’s insight into the problem and the client’s plans for managing it. • Option B: This portion of the health history focuses on questions related to the client’s past, from the earliest beginnings to the present. These questions elicit data related to the client’s strengths and weaknesses in her health history. The client’s strengths may be physical (e.g., optimal body weight), social (e.g., active in community services), emotional (e.g., expresses feeling openly), or spiritual (often turns to faith for support). • Option C: Information covered in the past health history includes questions about birth, growth, development, childhood diseases, immunizations, allergies, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, painful experiences, and emotional or psychiatric problems. 24. 24. Question John Joseph was scheduled for a physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs? • A. Dullness • B. Resonance • C. Hyperresonance • D. Tympany Incorrect Correct Answer: B. Resonance Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Since lungs are mostly filled with air that we breathe in, percussion performed over most of the lung area produces a resonant sound, which is a low-pitched, hollow sound. Therefore, any dullness or hyper-resonance is indicative of lung pathology, such as pleural effusion or pneumothorax, respectively. • Option A: Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation. Once an abnormality is detected, percussion can be used around the area of interest to define the extent of the abnormality. Normal areas of dullness are those overlying the liver and spleen at the anterior bases of the lungs. • Option C: Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lung. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyper resonance on one side of the chest may indicate a pneumothorax. • Option D: Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax. 25. 25. Question Matteo is diagnosed with dehydration and underwent a series of tests. Which laboratory result would warrant immediate intervention by the nurse? • A. Serum sodium level of 138 mEq/L • B. Serum potassium level of 3.1 mEq/L • C. Serum glucose level of 120 mg/dl • D. Serum creatinine level of 0.6 mg/100 ml Incorrect Correct Answer: B. Serum potassium level of 3.1 mEq/L A normal potassium level is 3.5 to 5.5 mEq/L. Hypokalemia is more prevalent than hyperkalemia, and most cases are mild. Severity is categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than 2.5 mmol/L. • Option A: A normal sodium level is 135 to 145 mEq/L. Among the electrolyte disorders, hyponatremia is the most frequent. Diagnosis is when the serum sodium level is less than 135 mmol/L. Hyponatremia has neurological manifestations. Patients may present with headache, confusion, nausea, delirium. Hypernatremia presents when the serum sodium levels are greater than145 mmol/L. • Option C: A normal non fasting glucose level is 85 to 140 mg/dl. Normal plasma glucose levels are defined as under 100 mg/dL during fasting and less than 140 mg/dL 2-hours postprandial. Additionally, glucose levels in healthy individuals can vary with age. Fasting plasma glucose in adults tends to increase with age starting in the third decade of life but does not increase significantly beyond 60 years of age. Normal HbA1c is lower than 5.7%. • Option D: A normal creatinine level is 0.2 to 0.8 mg/100 ml. Serum creatinine level for men with normal kidney function is approximately 0.6 to 1.2mg/dL and between 0.5 to 1.1 mg/dL for women. Alteration of serum creatinine values can occur as its generation is subject to influence by muscle function, activity, diet, and health status of the patient. Increased tubular secretion of creatinine in certain patients with dysfunctional kidneys could provide a false negative value. Elevated serum creatinine levels are also present in patients with muscular dystrophy paralysis, anemia, leukemia, and hyperthyroidism. 26. 26. Question During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury? • A. Tipping the client's head away from the examiner and pulling the ear up and back. • B. Inserting the otoscope inferiorly into the distal portion of the external canal. • C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal. • D. Bracing the examiner's hand against the client's head. Incorrect Correct Answer: C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal. In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two-thirds. It is important to avoid these structures during the examination. The provider should then slowly progress the speculum into the canal until the tympanic membrane becomes visible. The provider should evaluate the health of the tympanic membrane and observe factors such as color, presence of perforation, and a bulging appearance. • Option A: With the hand that is not holding the otoscope, the provider should grasp and gently pull the patient’s pinna to help straighten the patient’s external auditory canal. This step will facilitate visualization of the tympanic membrane. In a child, the examiner should pull the pinna posteriorly and inferiorly. In an adult, the examiner should pull the pinna posteriorly and superiorly. • Option B: During the otoscopic examination, the provider utilizes an otoscope, also known as an auriscope, to visualize the ear anatomy. While performing the otoscopic examination, the provider holds the handle of the otoscope and inserts the cone of the otoscope into the patient’s external auditory canal. • Option D: Providers may have their own preferences regarding how to grasp the otoscope. However, it is generally advisable to hold the otoscope like a pen in between the first and second fingers. The otoscope is usually held in the right hand when evaluating the patient’s right ear and the left hand when assessing the patient’s left ear. The provider should place their free fifth finger of the hand, holding the otoscope against the patient’s cheek to support and brace the hand during the examination. 27. 27. Question When assessing the lower extremities for arterial function, which intervention should the nurse perform? • A. Assessing the medial malleoli for pitting edema. • B. Performing Allen's test. • C. Assessing the Homans' sign. • D. Palpating the pedal pulses. Incorrect Correct Answer: D. Palpating the pedal pulses. Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Finding a pedal pulse is part of the trauma patient assessment and performed before and after lower extremity splint application as well as long backboard immobilization. Assessing a pedal pulse is part of the ongoing assessment for a patient on a backboard or a lower extremity splint. • Option A: Assessing the medial malleoli for pitting edema is appropriate for assessing the venous function of the lower extremity. The lower extremity examination should focus on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot. Pitting edema also occurs in the early stages of lymphedema because of an influx of protein-rich fluid into the interstitium, before fibrosis of the subcutaneous tissue; therefore, its presence should not exclude the diagnosis of lymphedema. • Option B: Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. The Allen test is a first-line standard test used to assess the arterial blood supply of the hand. This test is performed whenever intravascular access to the radial artery is planned or for selecting patients for radial artery harvesting, such as for coronary artery bypass grafting or for forearm flap elevation. • Option C: Homans’ sign is used to evaluate the possibility of deep vein thrombosis. Homan’s sign test also called dorsiflexion sign test is a physical examination procedure that is used to test for Deep Vein Thrombosis (DVT). A positive Homan’s A positive Homan’s sign in the presence of other clinical signs may be a quick indicator of DVT. 28. 28. Question Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves? • A. Breast • B. Integumentary • C. Ophthalmic • D. Oral Incorrect Correct Answer: D. Oral Gloves should be worn anytime there is a risk of exposure to the client’s blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client’s body fluids and do not require the nurse to wear gloves for protection. • Option A: After completing the visual inspection, the patient should be instructed to lay supine. If a site-specific breast complaint is being evaluated, the examiner should begin his/her exam on the opposite, or “normal” side. As one breast is examined, the other is covered for the patient’s comfort. The patient should place the ipsilateral hand above and/or behind their head to flatten the breast tissue as much as possible. The breast tissue itself is evaluated using a sequence of palpation that allows serial progression from superficial to deeper tissues. • Option B: A general assessment of the skin begins at the initial contact with the patient and continues throughout the examination. Specific areas of the skin are assessed during the examination of other body systems unless the chief complaint is a dermatologic problem. However, if there are areas of skin breakdown or drainage, gloves should be used. • Option C: The Royal College of Ophthalmologists have updated their advice on PPE to ophthalmologists and are now recommending that clinicians should wear standard surgical masks when examining or treating patients at the slit lamp. Gowns and gloves are not recommended. They also recommend that plastic breath shields attached to slit lamps provide some protection, but must be disinfected between patients as studies show that the COVID-19 virus is viable for up to 72 hours on plastic surfaces. 29. 29. Question Nurse Renner is about to perform Romberg’s test on Pierro. To ensure the latter’s safety, which intervention should nurse Renner implement? • A. Allowing the client to keep his eyes open. • B. Having the client hold on to furniture. • C. Letting the client spread his feet apart. • D. Standing close to provide support. Incorrect Correct Answer: D. Standing close to provide support. During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his shoulder, can prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results. • Option A: The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patient closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome. • Option B: In the Romberg test, the patient stands upright and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign. The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling. • Option C: The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body. If the clinician observes that the patient is able to stand for long periods of time with the eyes closed, it is evident that the patient’s balance and proprioceptive deficits have decreased. 30. 30. Question A physical assessment is being performed on patient Geoff by Nurse Tine. During the abdominal examination, Nurse Tine should perform the four physical examination techniques in which sequence? • A. Auscultation immediately after the inspection and then percussion and palpation. • B. Percussion, followed by inspection, auscultation, and palpation. • C. Palpation of tender areas first and then inspection, percussion, and auscultation. • D. Inspection and then palpation, percussion, and auscultation. Incorrect Correct Answer: A. Auscultation immediately after the inspection and then percussion and palpation With an abdominal assessment, auscultation always is performed before percussion and palpation because any abdominal manipulation, such as from palpation or percussion, can alter bowel sounds. Assessing the patient’s abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make the findings less accurate. • Option B: Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last. Assess for any visible mass, bulging, or asymmetry. Look for unusual coloring, scars, striae, lesions, petechiae, ecchymoses, spider angiomas, and suspicious-looking moles. Inspect the umbilicus and note any hernias. Look for pulsations. A thin patient may have a pulsation of the aorta in his epigastric area and possibly peristaltic waves. • Option C: Lightly percuss all four quadrants of the patient’s abdomen. You’ll hear dull sounds over solid structures (such as the liver) and fluid-filled structures (such as a full bladder). Air-filled areas (such as the stomach) produce tympany. Dullness is a normal finding over the liver, but a large, dull area elsewhere may indicate a tumor or mass. • Option D: Using a light, gentle, dipping motion, palpate for abnormalities, such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting fingers as you move from one location to another. After light palpation of the entire abdomen, place a non-dominant hand on the dominant hand to perform deeper palpation (1½ to 2 inches [3.8 to 5 cm]). However, avoid deep palpation if the patient may have a problem such as splenomegaly, appendicitis, or aneurysm or if palpation is painful for any reason. 31. 31. Question Which assessment data should the nurse include when obtaining a review of body systems? • A. Brief statement about what brought the client to the health care provider. • B. Client complaints of chest pain, dyspnea, or abdominal pain. • C. Information about the client's sexual performance and preference. • D. The client's name, address, age, and phone number. Incorrect Correct Answer: B. Client complaints of chest pain, dyspnea, or abdominal pain. Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This portion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac, respiratory, and abdominal. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. • Option A: A brief statement about what brought the client to the health care provider is the chief complaint. The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain). • Option C: Information about the client’s sexual performance and preference addresses past health status. Understanding the client’s current and past health is important and may provide an explanation or rationale for the client’s current health status. Furthermore, these data can provide insight into health promotion needs and co-morbidities. It is helpful to understand the current and past health profiles before assessing other aspects of health, as the information will inform subsequent questions. • Option D: The client’s name, address, age, and phone number are biographical data. “Introductory Information” refers to the demographic and biographic data that you collect from the client. This data provides you with basic characteristics about the client, such as their name, contact information, birth date and age, gender and preferred pronouns, allergies, languages spoken and preferred language, relationship status, occupation, and resuscitation status. 32. 32. Question Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview? • A. "What brought you to the clinic today?" • B. "Would you describe your overall health as good?" • C. "Do you understand what is happening?" • D. "Is there anything else you would like to tell me?" Incorrect Correct Answer: D. “Is there anything else you would like to tell me?” By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. • Option A: Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. The health history is typically done on admission to the hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013). • Option B: Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). • Option C: Asking if the client understands what is happening is a yes-or-no question that can elicit little information. Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but