GNUR 238 Exam 1: Focused Study and Practice
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse
conducts which type of assessment on his admission?
A. comprehensive assessment
B. problem-based assessment
C. episodic assessment
D. screening assessment for colorectal cancer - correct answer ✔✔A. comprehensive assessment:
detailed history and physical examination performed at the onset of care in a primary care setting,
admission to a hospital, or long term care facility. Encompasses health problems experienced by the
patient; health promotion, disease prevention, and assessment for problems associated with known risk
factors; or assessment for age and gender specific health problems
The formation of a plan of care is initiated with?
A. analysis of data
B. collection of data
C. clustering of data
D. identification of nursing diagnosis - correct answer ✔✔B. collection of data
During an interview the nurse learns that a patient has a 5 year history of hypertension. Which health
promotion intervention is most appropriate at this time?
A. teaching the patient how to relieve stress to prevent hypertension
B. monitoring and minimizing the progression of hypertension
C. establishing a screening schedule for detection of hypertension.
D. advising the patient on the benefits of exercise to lower blood pressure. - correct answer ✔✔B.
monitoring and minimizing the progression of hypertension
,A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What type of data
does this information represent?
A. subjective data
B. objective data
C. subjective and objective data
D. secondary source data - correct answer ✔✔C. subjective and objective data:
Signs are the objective data observed, felt, heard, or measured. Symptoms are subjective data perceived
and reported by the patient.
Which process does the clustering of data facilitate?
A. analyzing data
B. collecting data
C. implementing data
D. evaluating nursing care - correct answer ✔✔A. analyzing data
The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity
and acceptance of the patient?
A. "how often do you visit the medicine man for your health care?"
B. "tell me about your health care beliefs and practices."
C. "many Navajo people are afraid of hospitals. Are you afraid?"
D. 'have you ever had a physical examination with a physician or nurse practitioner?" - correct answer
✔✔B. "tell me about your health care beliefs and practices."
The nurse is conducting an interview with Jermey, a 17 year old accompanied by his mother. Which
statement by the nurse is an age appropriate adjustment when conducting a health history on an
adolescent?
A. Jermey, do you have a girlfriend, and if so are you sexually active?
,B. Mrs. Williams, is your son sexually active yet?
C. Jermey, how do you incorporate safe sex practices into your daily life?
D. Mrs. Williams, would you mind waiting outside for a few minutes while I discuss a few things with
Jermey? - correct answer ✔✔D. Mrs. Williams, would you mind waiting outside for a few minutes while I
discuss a few things with Jermey?
During an interview an elderly patient tells the nurse that she has periodic problems keeping her
balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom
analysis is the nurse pursuing with this question?
A. severity
B. frequency
C. aggravation factors
D. location - correct answer ✔✔C. aggravation factors
Which communication technique conveys genuine interest in what the patient has to say?
A. active listening
B. sitting close to the patient
C. maintaining professional dress conduct
D. holding the patient's hand during the interview - correct answer ✔✔A. active listening: involves
listening with a purpose to spoken words as well as noticing nonverbal behaviors. Do not predict how
the patient will respond or form the next question while the patient is talking.
A 62 year old patient tells the nurse that he is in excellent health and does not take any medication.
What is the most appropriate response by the nurse to follow up on the patient's statement?
A. do you avoid taking drugs because of bad experiences
B. which medications have you taken in the past
C. that is hard to believe. Most med your age take medications.
D. do you use over the counter medications or herbal preparations? - correct answer ✔✔D. do you use
over the counter medications or herbal preparations?
, The nurse obtains vital signs on a 42 year old man having his annual physical examination. He has no
medical conditions and states that his health is excellent. His blood pressure appears 62/40 using an
automated blood pressure device. Which action by the nurse is most appropiate?
A. obtain a different cuff and take the blood pressure again.
B. take the blood pressure again using the auscultation method.
C. place the patient in a supine position and take the pressure on the leg.
D. record the blood pressure and continue with the examination. - correct answer ✔✔B. take the blood
pressure again using the auscultation method.
Which set of vital signs should the nurse recognize as out of the expected range?
A. 42 year old man: BP 114/82; pulse 74; respiration 16; temperature 36.8 C
B. 11 year old girl: pulse 88; respiration 22; temperature 36.7 C
C. 3 year old boy: pulse 130; respiration 44; temperature 36.7 C
D. 1 month old girl: pulse 120; respiration 42; temperature 36.7 C - correct answer ✔✔C. 3 year old boy:
pulse 130; respiration 44; temperature 36.7 C
respirations should be 24-40.
The nurse records the following general inspection findings on a patient: "41 year old Hispanic male in
no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than
stated. Patient with flat affect and makes minimal eye contact." What addition information should be
added to this general inspection?
A. body movement
B. family history
C. estimated size of his liver
D. palpation of pulse - correct answer ✔✔A. body movement: general inspection begins the moment
you meet the patient. Involves observation of his or her physical appearance, hygiene, body structure,
body movement, emotional and mental status, and behavior.
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse
conducts which type of assessment on his admission?
A. comprehensive assessment
B. problem-based assessment
C. episodic assessment
D. screening assessment for colorectal cancer - correct answer ✔✔A. comprehensive assessment:
detailed history and physical examination performed at the onset of care in a primary care setting,
admission to a hospital, or long term care facility. Encompasses health problems experienced by the
patient; health promotion, disease prevention, and assessment for problems associated with known risk
factors; or assessment for age and gender specific health problems
The formation of a plan of care is initiated with?
A. analysis of data
B. collection of data
C. clustering of data
D. identification of nursing diagnosis - correct answer ✔✔B. collection of data
During an interview the nurse learns that a patient has a 5 year history of hypertension. Which health
promotion intervention is most appropriate at this time?
A. teaching the patient how to relieve stress to prevent hypertension
B. monitoring and minimizing the progression of hypertension
C. establishing a screening schedule for detection of hypertension.
D. advising the patient on the benefits of exercise to lower blood pressure. - correct answer ✔✔B.
monitoring and minimizing the progression of hypertension
,A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What type of data
does this information represent?
A. subjective data
B. objective data
C. subjective and objective data
D. secondary source data - correct answer ✔✔C. subjective and objective data:
Signs are the objective data observed, felt, heard, or measured. Symptoms are subjective data perceived
and reported by the patient.
Which process does the clustering of data facilitate?
A. analyzing data
B. collecting data
C. implementing data
D. evaluating nursing care - correct answer ✔✔A. analyzing data
The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity
and acceptance of the patient?
A. "how often do you visit the medicine man for your health care?"
B. "tell me about your health care beliefs and practices."
C. "many Navajo people are afraid of hospitals. Are you afraid?"
D. 'have you ever had a physical examination with a physician or nurse practitioner?" - correct answer
✔✔B. "tell me about your health care beliefs and practices."
The nurse is conducting an interview with Jermey, a 17 year old accompanied by his mother. Which
statement by the nurse is an age appropriate adjustment when conducting a health history on an
adolescent?
A. Jermey, do you have a girlfriend, and if so are you sexually active?
,B. Mrs. Williams, is your son sexually active yet?
C. Jermey, how do you incorporate safe sex practices into your daily life?
D. Mrs. Williams, would you mind waiting outside for a few minutes while I discuss a few things with
Jermey? - correct answer ✔✔D. Mrs. Williams, would you mind waiting outside for a few minutes while I
discuss a few things with Jermey?
During an interview an elderly patient tells the nurse that she has periodic problems keeping her
balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom
analysis is the nurse pursuing with this question?
A. severity
B. frequency
C. aggravation factors
D. location - correct answer ✔✔C. aggravation factors
Which communication technique conveys genuine interest in what the patient has to say?
A. active listening
B. sitting close to the patient
C. maintaining professional dress conduct
D. holding the patient's hand during the interview - correct answer ✔✔A. active listening: involves
listening with a purpose to spoken words as well as noticing nonverbal behaviors. Do not predict how
the patient will respond or form the next question while the patient is talking.
A 62 year old patient tells the nurse that he is in excellent health and does not take any medication.
What is the most appropriate response by the nurse to follow up on the patient's statement?
A. do you avoid taking drugs because of bad experiences
B. which medications have you taken in the past
C. that is hard to believe. Most med your age take medications.
D. do you use over the counter medications or herbal preparations? - correct answer ✔✔D. do you use
over the counter medications or herbal preparations?
, The nurse obtains vital signs on a 42 year old man having his annual physical examination. He has no
medical conditions and states that his health is excellent. His blood pressure appears 62/40 using an
automated blood pressure device. Which action by the nurse is most appropiate?
A. obtain a different cuff and take the blood pressure again.
B. take the blood pressure again using the auscultation method.
C. place the patient in a supine position and take the pressure on the leg.
D. record the blood pressure and continue with the examination. - correct answer ✔✔B. take the blood
pressure again using the auscultation method.
Which set of vital signs should the nurse recognize as out of the expected range?
A. 42 year old man: BP 114/82; pulse 74; respiration 16; temperature 36.8 C
B. 11 year old girl: pulse 88; respiration 22; temperature 36.7 C
C. 3 year old boy: pulse 130; respiration 44; temperature 36.7 C
D. 1 month old girl: pulse 120; respiration 42; temperature 36.7 C - correct answer ✔✔C. 3 year old boy:
pulse 130; respiration 44; temperature 36.7 C
respirations should be 24-40.
The nurse records the following general inspection findings on a patient: "41 year old Hispanic male in
no distress; very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than
stated. Patient with flat affect and makes minimal eye contact." What addition information should be
added to this general inspection?
A. body movement
B. family history
C. estimated size of his liver
D. palpation of pulse - correct answer ✔✔A. body movement: general inspection begins the moment
you meet the patient. Involves observation of his or her physical appearance, hygiene, body structure,
body movement, emotional and mental status, and behavior.
