160 exam 2
The nurse is assessing a pt who recently was Dx with a stroke. The pt is very emotional. In what part of
the brain did the stroke most likely occur? - correct answer ✔✔Limbic system
The nurse is caring for a pt in the mental health facility who has a Dx of bipolar disorder. The nurse know
that this is because mental health is directly affected by the - correct answer ✔✔Neurotransmitters
An insufficient amount of the neurotransmitter GABA may result in - correct answer ✔✔Anxiety
The nurse is using CAGE screening tool. This tool is used for what screen? - correct answer ✔✔Problem
alcohol use
nurse I performing a mental health assessment. Data collection for mental health assessment begins
when the nurse - correct answer ✔✔First sees the pt
Nurse notices that a pt has difficulty separating relevant from irrelevant information during a
conversation. This patient is having difficulty sirh - correct answer ✔✔Circumstantiality
The nurse is assessing pt stressors. Which tool can be used to identify the degree of stressors pt may be
experiencing - correct answer ✔✔Holmes social readjustment inventory scale
Nurse is planning to teach a group of pt stress reduction exercises to reduce risk of depression. Which
population group is at its highest for depression - correct answer ✔✔Adolescents
The nurse suspects altered thought processes. Which findings may suggest an alter thought process
(select all that apply) - correct answer ✔✔Problems articulating words
Cultural differences
The nurse is obtaining a mental health history of a new pt. What should the nurse include in the mental
health history? (Select all that apply) - correct answer ✔✔Past medical history
,Pt description of self
The nurse is assessing a patient's nutritional status and suspects the patient needs more macronutrients.
Which of the following are considered macronutrients? - correct answer ✔✔Fats
The nurse is teaching a patient the importance of protein for healing. Which foods should the nurse
include in the teaching plan? - correct answer ✔✔fish
The nurse is assessing a patient's dietary intake to help the patient lose weight. What is the easiest way
to assess the patient's normal dietary intake? - correct answer ✔✔Asking the patient to do a 24-hour
dietary recall
The nurse suspects that the patient is suffering from malnutrition. Which laboratory test indicates a
patient's protein calorie status? - correct answer ✔✔Serum albumin
The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the nurse
recommend for this patient? - correct answer ✔✔2 to 3
The nurse is assessing an elderly patient's risk of nutritional deficiency. An important risk factor for
nutritional deficiency in the elderly is: - correct answer ✔✔Decreased ADL
In which age group is skipping meals most commonly seen? - correct answer ✔✔Adolscents
According to the food plan, what represents one serving from the bread, cereal, and grain products
group? - correct answer ✔✔1 slice of bread
The nurse is working with a patient to develop a nutritional plan for a patient newly diagnosed with
diabetes. The nurse assesses what the patient's food preferences are because: - correct answer ✔✔food
preferences and dislikes have a strong influence on what a person eats.
The school nurse is assessing the nutritional status of a healthy adolescent. Which assessment will the
nurse include in this assessment? (Select all that apply.) - correct answer ✔✔Dietary assessment
Biochemical test results
, Anthropometrics
The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers
that react to touch, pain, and temperature? - correct answer ✔✔dermis
The nurse is performing a skin assessment and finds that the patient has milia. In which age group would
this be an expected finding? - correct answer ✔✔newborns
A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks
the nurse what could be causing this? The nurse's best response is: - correct answer ✔✔Macules are
freckles are considered normal on the skin
The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears
as a(n): - correct answer ✔✔Ashen gray color to the skin
The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? - correct
answer ✔✔The angle of the nail base
A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further
investigate a lesion? - correct answer ✔✔The lesion bleeds easily when it is touched.
The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected
finding? - correct answer ✔✔older adults
The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What
would the nurse include as the most common cause of skin lesions for this age group? - correct answer
✔✔Communicable disease and bacterial infection
The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: - correct answer ✔✔pinching the
skin and watching the skin return to place
The nurse knows that the functions of the skin include which of the following? (Select all that apply.) -
correct answer ✔✔-Sensory input
The nurse is assessing a pt who recently was Dx with a stroke. The pt is very emotional. In what part of
the brain did the stroke most likely occur? - correct answer ✔✔Limbic system
The nurse is caring for a pt in the mental health facility who has a Dx of bipolar disorder. The nurse know
that this is because mental health is directly affected by the - correct answer ✔✔Neurotransmitters
An insufficient amount of the neurotransmitter GABA may result in - correct answer ✔✔Anxiety
The nurse is using CAGE screening tool. This tool is used for what screen? - correct answer ✔✔Problem
alcohol use
nurse I performing a mental health assessment. Data collection for mental health assessment begins
when the nurse - correct answer ✔✔First sees the pt
Nurse notices that a pt has difficulty separating relevant from irrelevant information during a
conversation. This patient is having difficulty sirh - correct answer ✔✔Circumstantiality
The nurse is assessing pt stressors. Which tool can be used to identify the degree of stressors pt may be
experiencing - correct answer ✔✔Holmes social readjustment inventory scale
Nurse is planning to teach a group of pt stress reduction exercises to reduce risk of depression. Which
population group is at its highest for depression - correct answer ✔✔Adolescents
The nurse suspects altered thought processes. Which findings may suggest an alter thought process
(select all that apply) - correct answer ✔✔Problems articulating words
Cultural differences
The nurse is obtaining a mental health history of a new pt. What should the nurse include in the mental
health history? (Select all that apply) - correct answer ✔✔Past medical history
,Pt description of self
The nurse is assessing a patient's nutritional status and suspects the patient needs more macronutrients.
Which of the following are considered macronutrients? - correct answer ✔✔Fats
The nurse is teaching a patient the importance of protein for healing. Which foods should the nurse
include in the teaching plan? - correct answer ✔✔fish
The nurse is assessing a patient's dietary intake to help the patient lose weight. What is the easiest way
to assess the patient's normal dietary intake? - correct answer ✔✔Asking the patient to do a 24-hour
dietary recall
The nurse suspects that the patient is suffering from malnutrition. Which laboratory test indicates a
patient's protein calorie status? - correct answer ✔✔Serum albumin
The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the nurse
recommend for this patient? - correct answer ✔✔2 to 3
The nurse is assessing an elderly patient's risk of nutritional deficiency. An important risk factor for
nutritional deficiency in the elderly is: - correct answer ✔✔Decreased ADL
In which age group is skipping meals most commonly seen? - correct answer ✔✔Adolscents
According to the food plan, what represents one serving from the bread, cereal, and grain products
group? - correct answer ✔✔1 slice of bread
The nurse is working with a patient to develop a nutritional plan for a patient newly diagnosed with
diabetes. The nurse assesses what the patient's food preferences are because: - correct answer ✔✔food
preferences and dislikes have a strong influence on what a person eats.
The school nurse is assessing the nutritional status of a healthy adolescent. Which assessment will the
nurse include in this assessment? (Select all that apply.) - correct answer ✔✔Dietary assessment
Biochemical test results
, Anthropometrics
The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers
that react to touch, pain, and temperature? - correct answer ✔✔dermis
The nurse is performing a skin assessment and finds that the patient has milia. In which age group would
this be an expected finding? - correct answer ✔✔newborns
A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks
the nurse what could be causing this? The nurse's best response is: - correct answer ✔✔Macules are
freckles are considered normal on the skin
The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears
as a(n): - correct answer ✔✔Ashen gray color to the skin
The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? - correct
answer ✔✔The angle of the nail base
A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further
investigate a lesion? - correct answer ✔✔The lesion bleeds easily when it is touched.
The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected
finding? - correct answer ✔✔older adults
The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What
would the nurse include as the most common cause of skin lesions for this age group? - correct answer
✔✔Communicable disease and bacterial infection
The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: - correct answer ✔✔pinching the
skin and watching the skin return to place
The nurse knows that the functions of the skin include which of the following? (Select all that apply.) -
correct answer ✔✔-Sensory input
