Health Assessment NCLEX Questions with 100% Correct Solutions

According to the holistic model, a narrow definition of holistic health includes: A. an optimal functioning of mind, body, and spirit within the environment. Incorrect B. the absence of disease. C. the response of the whole person to actual or potential problems. D. the internal and external environment. - ANSWER B From a biomedical perspective, health is defined as the absence of disease or elimination of symptoms and signs of disease, whereas a holistic model approach examines mind, body, and spirit working interdependently within the environment to maintain health and well-being. Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. In a holistic model approach to health, both the internal and the external environment affect a patient's health and well-being. What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures? A. Episodic B. Follow-up C. Emergency D. Complete - ANSWER C An emergency database includes rapid collection of data often obtained concurrently with lifesaving measures. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. A medical diagnosis is used to evaluate: A. a person's state of health. B. the response of the whole person to actual or potential health problems. C. a person's culture. D. the cause of disease. - ANSWER D. Medical diagnoses are used to evaluate the cause or etiology of disease. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems. The holistic model of health care is used in nursing, and culture is an important factor to consider in a nursing assessment. An example of subjective data is: A. decreased range of motion. B. crepitation in the left knee joint. C. left knee has been swollen and hot for the past 3 days. D. arthritis. - ANSWER C Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpating. Arthritis is a medical diagnosis. What type of database is most appropriate for an individual who is admitted to a long-term care facility? A. Episodic B. Follow-up C. Emergency D. Complete - ANSWER D A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. An emergency database includes rapid collection of data often obtained concurrently with lifesaving measures. Which of the following is an example of objective data? A. Alert and oriented B. Dizziness C. An earache D. A sore throat - ANSWER A Objective data is what the health professional observes; level of consciousness and orientation are observations. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking. An example of objective data is: A. a complaint of left knee pain. B. crepitation in the left knee joint. C. left knee has been swollen and hot for the past 3 days. D. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion. - ANSWER B Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking. A nursing diagnosis is best described as: A. a determination of the etiology of disease. B. a pattern of coping. C. an individual's perception of health. D. a concise statement of actual or potential health concerns or level of wellness. - ANSWER D Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. Medical diagnoses determine the cause or etiology of disease. Coping patterns include methods to relieve stress. Health perception is how the person describes and defines personal health. A complete database is: A. used to collect data rapidly and is often compiled concurrently with lifesaving measures. B. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. C. used to evaluate the cause or etiology of disease. D. used to perform a thorough or comprehensive health history and physical examination. - ANSWER D A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An emergency database is rapid collection of data often obtained concurrently with lifesaving measures. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. Medical diagnoses are used to evaluate the cause or etiology of disease. A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? A. Ineffective self-health management B. Risk for infection C. Impaired gas exchange D. Readiness for enhanced spiritual well-being - ANSWER C First-level priority problems are problems that are emergent, life-threatening, and immediate. Impaired gas exchange is an emergent and immediate problem. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Ineffective self-health management is an example of a third-level priority. Second-level priority problems are problems that are next in urgency; these problems require prompt intervention to forestall further deterioration. Risk for infection is an example of a second-level priority. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Wellness diagnoses are third-level priority problems. Each culture has its own healers who usually: A. speak at least two languages. B. own and operate specialty community clinics. C. cost less than traditional or biomedical providers. D. recommend folk practices that are dangerous. - ANSWER C Most healers cost significantly less than healers practicing in the biomedical or scientific health care system. Most healers speak the person's native tongue. Most healers make house calls. Most health practices used by folk healers are not dangerous and are usually harmless. While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following would most likely describe this patient's view of wellness? A. Good is hot. B. Evil is hot. C. The humors must be balanced. D. The phlegm will be replaced with dryness. - ANSWER C The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the balance of the humors. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. The four humors of the body include the blood, phlegm, black bile, and yellow bile; the humors regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. On the basis of median age: A. the non-Hispanic white population tends to be younger. B. the Hispanic population tends to be older. C. the Asian population tends to be younger. D. minorities tend to be older than non-Hispanic white populations. - ANSWER C The Asian population is younger with a median age of 36 years. The non-Hispanic, single-race white population is older than the population as a whole; the respective median age is 40.2 years. The Hispanic population is much younger, with a median age of 27.7 years. Minorities tend to be younger than non-Hispanic white populations. Spirituality is defined as: A. participating in religious services on a regular basis. B. a personal effort to find meaning and purpose in life. C. the process of being raised within a culture. D. a social group that claims to possess variable traits. - ANSWER B Spirituality is a personal effort to find purpose and meaning in life. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Ethnicity pertains to a social group within the social system that claims to possess variable traits. Which of the following statements regarding language barriers and health care is true? A. There is a law that addresses language barriers and health care. B. Limited English proficiency is associated with a higher quality of care. C. English proficiency is associated with a lower quality of care. D. Patients with language barriers have a decreased risk of nonadherence to medication regimens. - ANSWER A Title VI of the Civil Rights Act of 1964 provides people with limited English proficiency access to health care; these individuals cannot be denied health care services. Limited English proficiency is associated with a lower quality of care. English proficiency is associated with a higher quality of care. Patients with language barriers have an increased risk of nonadherence to medication regimens. What is the yin/yang theory of health? A. Health exists when all aspects of the person are in perfect balance. B. Health exists when physical, psychological, spiritual, and social needs are met. C. Health exists in the absence of illness. D. Health exists when there is optimal functioning. - ANSWER A In the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance. In the hot/cold theory, health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. The biomedical model of Western tradition views health as the absence of disease. In the biomedical or scientific theory, high-level wellness (or health) exists with optimal functioning of the human body. Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? A. Behavior theory B. Heritage consistency C. Congruence mechanism D. Socialization experience - ANSWER B Heritage consistency theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage. Behavior theory or behaviorism is a learning theory. Carl Rogers described the concepts of congruence and incongruence as important ideas in his theory of personality and human development. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Which of the following symptoms is greatly influenced by a person's cultural heritage? A. Hearing loss B. Pain C. Breast lump D. Food intolerance - ANSWER B Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain all are embedded in a cultural context. Hearing loss is more common in whites than in blacks. The incidence of breast cancer varies with different cultural groups. Food intolerance varies with different cultural groups. For example, lactose intolerance is common in African Americans, American Indians, and Asian Americans. When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.) A. his or her own heritage. B. cultural and ethnic values. C. the heritage of the nursing profession. D. the heritage of the patient. E. the heritage of the health care system. - ANSWER A, C, D, E Discrete areas of knowledge for cultural competence include understanding of one's own heritage, the heritage of the nursing profession, the heritage of the patient, and the heritage of the health care system. Understanding cultural and ethnic values is not an area of knowledge for cultural competence. When preparing the physical setting for an interview, the interviewer should: A. set the room temperature between 64° F and 66° F. B. reduce noise by turning the volume on the television or radio down. C. conduct the interview at eye level and at a distance of 4 to 5 feet. D. stand next to the patient to convey a professional demeanor. - ANSWER C Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet. The room temperature should be set at a comfortable level; a temperature between 64° F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment to reduce noise. The interviewer and the patient should be comfortably seated; standing communicates haste and assumes superiority. Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms. A. 5 B. 7 C. 9 D. 11 - ANSWER B School-age children (starting at age 7) have the verbal ability to add important data to the history. The nurse should interview the parent and child together, but when a presenting symptom or sign exists, the nurse should ask the child about it first and then gather data from the parent. Which of the following statements made by the interviewer would be an appropriate response? A. "I know just how you feel." B. "If I were you, I would have the surgery." C. "Why did you wait so long to make an appointment?" D. "Tell me what you mean by 'bad blood.'" - ANSWER D "Tell me what you mean by 'bad blood'" is an appropriate communication technique referred to as seeking further clarification. "I know just how you feel" is an inappropriate communication technique referred to as false reassurance. "If I were you, I would have the surgery" is an inappropriate communication technique referred to as giving unwanted advice. "Why did you wait so long to make an appointment?" is an inappropriate communication technique referred to as using "Why" questions. While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation: A. affects the nurse-physician relationship. B. impedes further discussion. C. helps the patient understand personal feelings in relation to his or her verbal message. D. helps the nurse understand his or her own feelings in relation to the patient's verbal message. - ANSWER C Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient's personal feelings in relation to the patient's verbal message. The nurse-physician relationship is not the barrier to communication in this situation. The interpretation by the nurse will improve communication. The nurse's feelings are not the barrier to communication in this situation. The use of euphemisms to avoid reality or to hide feelings is known as: A. distancing language. B. sympathetic language. C. avoidance language. D. ethnocentric language. - ANSWER C Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior. When addressing a toddler during the interview, the health care provider should: A. ask the child, before the caretaker, about symptoms. B. use nonverbal communication. C. use short, simple, concrete sentences. D. use detailed explanations. - ANSWER C A toddler's communication is direct, concrete, literal, and set in the present. The health care provider should use short, simple sentences with concrete explanations. For a younger child such as a toddler, the parent will provide all or most of the history. Nonverbal communication is the primary communication method for infants. Detailed explanations would be more appropriate for a school-age child, adolescent, or adult. Nonverbal communication is the primary form of communication for which group of individuals? A. Infants B. Preschoolers C. Adolescents D. Older adults - ANSWER A Nonverbal communication is the primary communication method for infants. Preschoolers' communication is direct, concrete, literal, and set in the present. Adolescents should be treated with respect; the nurse should use open, honest, professional communication. Older adults may need special considerations related to physical limitations (e.g., adjusted pace to avoid fatigue, impaired hearing). Viewing the world from another person's inner frame of reference is called: A. reflection. B. empathy. C. clarification. D. sympathy. - ANSWER B Empathy means viewing the world from the other person's inner frame of reference. Reflection is repeating part of what the person has just said. Clarification is used to summarize the person's words or to simplify the words to make them clearer. Sympathy is a social affinity in which one person stands with another person, closely understanding his or her feelings. An example of an open-ended question or statement is: A. "Tell me about your pain." B. "On a scale of 1 to 10, how would you rate your pain?" C. "I can see that you are quite uncomfortable." D. "You are upset about the level of pain, right?" - ANSWER A Open-ended questions and statements ask for narrative information; they state the topic to be discussed but only in general terms. "Tell me about your pain" encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen. "On a scale of 1 to 10, how would you rate your pain?"; "I can see that you are quite uncomfortable"; and "You are upset about the level of pain, right?" are closed or direct questions. Closed or direct questions and statements ask for specific information. This type of question or statement will elicit a short, one- or two-word answer, a yes or no response, or a forced choice. The most appropriate introduction to use to start an interview with an older adult patient is: A. "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." B. "David, I am here to ask you questions about your illness; we want to determine what is wrong." C. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" D. "Because so many people have already asked you questions, I will just get the information from the chart." - ANSWER A An older adult should be addressed by the last name; older adults may be offended by a younger person using their first names. The initial introduction should include the person's surname (unless a child) and the reason for the interview. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" is a closed-ended question. "Because so many people have already asked you questions, I will just get the information from the chart" does not allow for free expression of ideas. Which of the following is included in documenting a history source? A. Appearance, dress, and hygiene B. Cognition and literacy level C. Documented relationship of support systems D. Reliability of informant - ANSWER D The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history. A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about: A. the patient's perception of pain. B. the nature or character of the headache. C. aggravating factors. D. relieving factors. - ANSWER C Aggravating factors are determined by asking the patient what makes the pain worse. To determine the patient's perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means. The nature or character calls for specific descriptive terms to describe the pain. Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help. The CAGE test is a screening questionnaire that helps to identify: A. unhealthy lifestyle behaviors. B. personal response to stress. C. excessive or uncontrollable drinking. D. depression. - ANSWER C CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. The "review of systems" in the health history is: A. an evaluation of past and present health state of each body system. B. a documentation of the problem as perceived by the patient. C. a record of objective findings. D. a short statement of general health status. - ANSWER A The purpose of the review of systems is to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. The reason for seeking care is a statement in the person's own words that describes the reason for the visit. This is typically known as a "chief complaint" or the reason for the health care visit. Objective data are the observations obtained by the health care professional during the physical examination. A short statement related to the patient's general health status is typically included in the complete physical assessment record. When recording information for the review of systems, the interviewer must document: A. physical findings, such as skin appearance, to support historic data. B. "negative" under the system heading. C. the presence or absence of all symptoms under the system heading. D. objective data that support the history of present illness. - ANSWER C When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms; otherwise it is unknown which factors were asked. Recording physical findings in the review of systems is incorrect; review of systems is limited to the patient's statements or subjective data. Writing "negative" after the system heading is also incorrect because it would be unknown which factors were asked. Recording objective data in the review of systems is incorrect; review of systems is limited to the patient's statements or subjective data. Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include: A. education, financial status, and value-belief system. B. exercise and activity, leisure activities, and level of independence. C. family role, interpersonal relations, social support, and time spent alone. D. stressors, coping mechanisms, and change in past year. - ANSWER A Functional assessment measures a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. These areas are related to the activity and exercise section of the functional assessment. These areas are related to the interpersonal relationships and resources section of the functional assessment. These areas are related to the coping and stress management section of the functional assessment. PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to: A. severity of dementia. B. substance use and abuse. C. pain presentation. D. the ability to perform activities of daily living (ADLs). - ANSWER C The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person's self-care ability including the ability to perform ADLs. The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to: A. review previous medical records. B. rephrase the same questions later in the interview. C. ask the patient if there is someone who could verify information. D. call a family member to confirm information. - ANSWER B A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corrobation of information from another individual is not within the context of the present interview. This would occur outside the context of the interview. When taking a health history from an adolescent, the interviewer should: A. ask about violence and abuse before asking about alcohol and drug use. B. have at least one parent present during the interview. C. interview the youth alone with a parent in the waiting area. D. ask every youth about the use of condoms. - ANSWER C The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (related to injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and situational questions. What information is included in greater detail when taking a health history on an infant? A. Nutritional data B. History of present illness C. Family history D. Environmental hazards - ANSWER A The amount of nutritional information needed depends on the child's age; the younger the child is, the more detailed and specific the data should be. The health history is adapted to include information specific for the age and developmental stage of the child (e.g., mother's health during pregnancy, labor, and delivery and the perinatal period). The developmental history and nutritional data are important for current health of infants and children. To examine a toddler, the nurse should: A. allow the child to sit on the parent's lap. B. remove the child's clothing at the beginning of the examination. C. ask the child to decide whether parents or siblings should be present. D. perform the assessment from head to toes. - ANSWER A A toddler should be sitting up on the parent's lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child who is 11 or 12 years old to decide whether parents or siblings should be present. The sequence of the examination for a toddler should start with nonthreatening areas first; save distressing procedures such as assessment of the head, ears, nose, or throat for last. Deep palpation is used to: A. identify abdominal contents. B. evaluate surface characteristics. C. elicit deep tendon reflexes. D. determine the density of a structure. - ANSWER A Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.