NR302 / NR-302 Final Exam (Latest Update 2025 / 2026): Health Assessment | Complete Guide with Questions and Verified Answers | 100% Correct - Chamberlain

NR302 / NR-302 Final Exam (Latest Update 2025 / 2026): Health Assessment | Complete Guide with Questions and Verified Answers | 100% Correct - Chamberlain 1. The concept of health and healing has evolved in recent years. Which is the best description of health? a. Health is the absence of disease. b. Health is a dynamic process toward optimal functioning. c. Health depends on an interaction of mind, body, and spirit within the environment. d. Health is the prevention of disease. >>>Ans>>>> c. Health depends on an interaction of mind, body, and spirit within the environment. 2. Which would be included in the database for a new patient admission to a surgical unit? a. All subjective and objective data gathered by a health practitioner from a patient b. All objective data obtained from a patient through inspection, percussion, palpation, and auscultation c. A summary of a patient's record, including laboratory studies >>>Ans>>>> d. All subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed d. All subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed 3. You are reviewing assessment data of a 45-year-old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of: a. Hypothetical reasoning b. Diagnostic reasoning c. Data cluster d. Signs and symptoms >>>Ans>>>> . Data cluster 4. A patient is in the emergency department with nausea and vomiting. Which would you include in the database? a. A complete health history and full physical examination b. A diet and GI history c. Previously identified problems d. Start collection of data in conjunction with lifesaving measures >>>Ans>>>> b. A diet and GI history 5. A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond? a. "It would be most efficient if you visit on an annual basis." b. "There is no recommendation for the frequency of health care visits." c. "Your visits may vary, depending on your level of wellness." d. "Your visits will be based on your preference." >>>Ans>>>> c. "Your visits may vary, depending on your level of wellness." 6. You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a. Planning b. Assessment c. Implementation d. Diagnosis >>>Ans>>>> a. Planning 7. Which best describes evidence-based nursing practice? a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances b. Appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices d. Finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances 8. What can be determined when the nurse clusters data as part of the critical-thinking process? a. This step identifies problems that may be urgent and require immediate action. b. This step involves making assumptions in the data. c. The nurse recognizes relevant information among the data. d. Risk factors can be determined so the nurse knows how to offer health teaching. >>>Ans>>>> c. The nurse recognizes relevant information among the data. 9. A patient says she is very nervous and nauseated, and she feels like she will vomit. This data would be what type of data? a. Objective b. Reflective c. Subjective d. Introspective >>>Ans>>>> c. Subjective 10. The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as: a. Deductive reasoning b. Intuition c. The nursing process d. Focus assessment >>>Ans>>>> b. Intuition 11. Which would be considered a risk diagnosis? a. Identifying existing levels of wellness b. Evaluating previous problems and goals c. Identifying potential problems the individual may develop d. Focusing on strengths and reflecting an individual's transition to higher levels of wellness >>>Ans>>>> c. Identifying potential problems the individual may develop 12. Which would be included in a holistic model of assessment? a. Nursing goals for the patient b. Anticipated growth and development patterns c. A patient's perception of his or her health status d. The nurse's perception of disease related to the patient >>>Ans>>>> c. A patient's perception of his or her health status 13. The nurse uses health promotion activities with a new patient. What would this focus include? a. The nurse would try to change the patient's perceptions of disease. b. The nurse would search for identification of biomedical model interventions. c. The nurse would help to identify negative health acts of the patient. d. The nurse would empower the patient to choose a healthier lifestyle. >>>Ans>>>> d. The nurse would empower the patient to choose a healthier lifestyle. 14. Which is an example of objective data? a. Patient's history of allergies b. Patient's use of medications at home c. Last menstrual period 1 month ago d. 2- × 5-cm scar present on the right lower forearm >>>Ans>>>> d. 2- × 5-cm scar present on the right lower forearm 15. During the evaluation phase of the nursing process, which action would be included? a. Validating the nursing diagnosis b. Establishing priorities related to patient care c. Providing information to the patient and family members d. Establishing a timeline for planned outcomes >>>Ans>>>> c. Providing information to the patient and family members 1. Which statement best describes religion? a. An organized system of beliefs concerning the cause, nature, and purpose of the universe b. Belief in a divine or superhuman spirit to be obeyed and worshiped c. Affiliation with one of the 1200 recognized religions in the United States d. The following of established rituals, especially in conjunction with health-seeking behaviors >>>Ans>>>> a. An organized system of beliefs concerning the cause, nature, and purpose of the universe 2. The major factor contributing to the need for cultural care nursing is: a. An increasing birth rate b. Limited access to health care services c. Demographic change d. A decreasing rate of immigration >>>Ans>>>> c. Demographic change 3. The term culturally competent implies that the nurse: a. Is prepared in nursing. b. Possesses knowledge of the traditions of diverse peoples. c. Applies underlying knowledge to providing nursing care. d. Understands the cultural context of the patient's situation. >>>Ans>>>> d. Understands the cultural context of the patient's situation. 4. You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional respectful demeanor b. Allowing for additional time to complete the process c. Providing the patient with a paper and pencil so he or she can write down the answers to the questions that you are going to ask d. Seeing if there are any family members present who may assist with the interview process >>>Ans>>>> c. Providing the patient with a paper and pencil so he or she can write down the answers to the questions that you are going to ask 5. Which culture would describe illness as hot and cold imbalance? a. Asian-American heritage b. African-American heritage c. Hispanic-American heritage d. American Indian heritage >>>Ans>>>> c. Hispanic-American heritage 6. Of what does the patient believe the amulet is protective? a. The evil eye b. Being kidnapped c. Exposure to bacterial infections d. An unexpected fall >>>Ans>>>> a. The evil eye 7. Which statement best illustrates the difference between religion and spirituality? a. Religion reflects an individual's reaction to life events whereas spirituality is based on whether the individual attends religious services. b. Religion is characterized by identification of a higher being shaping one's destiny while spirituality reflects an individual's perception of one's life having worth or meaning. c. Religion is the expression of spiritual awakening whereas spirituality is based on belief in divine right. >>>Ans>>>> d. Religion is the active interpretation of one's spirituality. b. Religion is characterized by identification of a higher being shaping one's destiny while spirituality reflects an individual's perception of one's life having worth or meaning. 8. The first step to cultural competency by a nurse is to: a. Identify the meaning of health to the patient. b. Understand how a health care delivery system works. c. Develop a frame of reference to traditional health care practices. d. Understand your own heritage and its basis in cultural values. >>>Ans>>>> d. Understand your own heritage and its basis in cultural values. 9. Which statement is true in regard to pain? a. Nurses' attitudes toward their patients' pain are unrelated to their own experiences with pain. b. The cultural background of a patient is important in a nurse's assessment of that patient's pain. c. A nurse's area of clinical practice is most likely to determine his or her assessment of a patient's pain. d. A nurse's years of clinical experience and current position are a strong indicator of his or her response to patient pain. >>>Ans>>>> . The cultural background of a patient is important in a nurse's assessment of that patient's pain. 10. Which factor is identified as a priority influence on a patient's health status? a. Poverty b. Lifestyle factors c. Legislative action d. Occupational status a. Poverty 11. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient? a. "Are you of the Christian faith?" b. "Do you want to see a medicine man?" c. "How often do you seek help from medical providers?" d. What cultural or spiritual beliefs are important to you?" d. What cultural or spiritual beliefs are important to you?" 12. Which statement best describes ethnocentrism? a. The government's description of various cultures b. A central belief that accepts all cultures as one's own c. The tendency to view your own way of life as the most desirable d. The tendency to impose your beliefs, values, and patterns of behaviors on an individual from another culture c. The tendency to view your own way of life as the most desirable 13. Which category is appropriate in a cultural assessment? a. Family history b. Chief complaint c. Past medical history d. Health-related beliefs d. Health-related beliefs 14. Which health belief practice is associated with patients who are of American Indian heritage? a. Wearing bangle bracelets to ward off evil spirits b. Eating compatible foods in one's diet c. Using swamp root as a traditional home remedy d. Believing in a shaman as a traditional healer b. Eating compatible foods in one's diet 15. Which statement best reflects the Magicoreligious causation of illness? a. Each being is but a part of a larger structure in the world of nature as it relates to health and illness. b. Causality relationship exists leading to expression of illness. c. Belief in the struggle between good and evil is reflected in the regulation of health and illness. d. Illness occurs as a result of disturbances between hot and cold reactions. c. Belief in the struggle between good and evil is reflected in the regulation of health and illness. 1. The practitioner, entering the examining room to meet a patient for the first time, states: "Hello, I'm M.M., and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it's all right with you, she will remain during the examination." Which of the following must be added to cover all aspects of the interview contract? a. A statement regarding confidentiality, patient costs, and the expectations of each person b. The purpose of the interview and the role of the interviewer c. Time and place of the interview and a confidentiality statement d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies a. A statement regarding confidentiality, patient costs, and the expectations of each person 2. ______________ is exhibiting an accurate understanding of the other person's feelings within a communication context. a. Empathy b. Liking others c. Facilitation d. A nonverbal listening technique a. Empathy 3. You conduct an admission interview. Because you are expecting a phone call, you stand near the door. Which would be a more appropriate approach? a. Arrange to have someone page you so you can sit on the side of the bed. b. Have someone else answer the phone so you can sit facing the patient. c. Use this approach given the circumstances. d. Arrange for a time free of interruptions after the initial physical examination is complete. b. Have someone else answer the phone so you can sit facing the patient. 4. A patient asks the nurse, "May I ask you a question?" This is an example of: a. An open-ended question b. A reflective question c. A closed question d. A double-barreled question c. A closed question 5. Which statement best describes interpretation as a communication technique? a. Interpretation is the same as clarification. b. Interpretation is a summary of a statement made by a patient. c. Interpretation is used to focus on a particular aspect of what the patient has just said. d. Interpretation is based on the interviewer's inference from the data that have been presented. d. Interpretation is based on the interviewer's inference from the data that have been presented. 6. Which demonstrates a good understanding of the interview process? a. The nurse stops the patient each time something is said that is not understood. b. The nurse spends more time listening to the patient than talking. c. The nurse is consistently thinking of his or her next response so the patient will know he or she is understood. d. The nurse uses "why" questions to seek clarification of unusual symptoms or behavior. b. The nurse spends more time listening to the patient than talking. 7. During an interview, a patient denies having any anxiety. The patient frequently changes position in the chair, holds his arms folded tight against his chest, and has little eye contact with the interviewer. The interviewer should: a. Use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patient's attention. b. Proceed with the interview. Patients usually are truthful with a health care practitioner. c. Make a mental note to discuss the behavior after the physical examination is completed. d. Proceed with the interview and examination as outlined on the agency assessment form. The patient's behavior is appropriate for the circumstances. a. Use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patient's attention. 8. For what or with whom should touch be used during the interview? a. Only with individuals from a Western culture b. As a routine way of establishing contact with the person and communicating empathy c. Only with patients of the same gender d. Only if the interviewer knows the person well d. Only if the interviewer knows the person well 9. Children usually come for health care with a parent. At about what age should the interviewer begin to question the child himself or herself regarding presenting symptoms? a. 5 years b. 7 years c. 9 years d. 11 years b. 7 years 10. Because of adolescents' developmental level, not all interviewing techniques can be used with them. Which techniques should be avoided? a. Facilitation and clarification b. Confrontation and explanation c. Empathy and interpretations d. Silence and reflection d. Silence and reflection 11. Knowledge of the use of personal space is helpful for the health care provider. Personal distance is generally considered to be: a. 0 to 1.5 feet. b. 1.5 to 4 feet. c. 4 to 12 feet d. 12 or more feet. b. 1.5 to 4 feet. 12. Mr. B. tells you, "Everyone here ignores me." You respond, "Ignores you?" This technique is best described as: a. Clarification. b. Selective listening. c. Reflecting. d. Validation. c. Reflecting. 13. What does active listening NOT include? a. Taking detailed notes during the interview b. Watching for clues in body language c. Repeating statements back to the person to make sure you have understood d. Asking open-ended questions to explore the person's perspective a. Taking detailed notes during the interview 14. When interviewing a patient who does not speak English, the examiner should: a. Take advantage of family members who are readily available and willing to assist. b. Use a qualified medical interpreter who is culturally literate. c. Seek as much information as possible and then continue with the physical examination. d. Wait until a qualified medical interpreter is available before starting the interview. b. Use a qualified medical interpreter who is culturally literate. 15. With older adults, how should the examiner proceed with the interview? a. Proceed in a more organized and concise manner. b. Consider the fatigue of the older person and break the interview into shorter segments. c. Ask a family member to complete some of the records while moving ahead with the interview. d. Raise your voice if the patient does not appear to hear you. b. Consider the fatigue of the older person and break the interview into shorter segments. 1. When reading a medical record, you see the following notation: Patient states, "I have had a cold for about a week, and now I am having difficulty breathing." This is an example of: a. A past health history. b. A review of systems. c. A functional assessment. d. A reason for seeking care. d. A reason for seeking care. 2. You have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is to: a. Rephrase the same questions later in the interview. b. Review the patient's previous medical records. c. Call the person identified as the emergency contact to verify the data provided. d. Provide the patient with a printed history to complete and then compare the data provided. a. Rephrase the same questions later in the interview. 3. The statement "Reason for seeking care" has replaced the "chief complaint." This change is significant because: a. The "chief complaint" is really a diagnostic statement. b. The newer term allows another individual to supply the necessary information. c. The newer term incorporates wellness needs. d. The "reason for seeking care" can incorporate the history of the present illness. c. The newer term incorporates wellness needs. 4. During an initial interview, the examiner says, "Mrs. J., tell me what you do when your headaches occur?" This is an example of which type of information? a. The patient's perception of the problem b. Aggravating or relieving factors c. The frequency of the problem d. The severity of the problem b. Aggravating or relieving factors 5. Which is an appropriate recording of a patient's reason for seeking health care? a. Angina pectoris, duration 2 hours b. Substernal pain radiating to left axilla, 1 hour duration c. "Grabbing" chest pain for 2 hours d. Pleurisy, 2 days' duration c. "Grabbing" chest pain for 2 hours 6. A genogram is used for which reasons? a. Past history b. Past health history, specifically hospitalizations c. Family history d. The 8 characteristics of presenting symptoms c. Family history 7. What is the best description of "review of systems" as a part of the health history? a. The evaluation of the past and present health state of each body system b. A documentation of the problem as described by the patient c. The recording of the objective findings of the practitioner d. A statement that describes the overall health state of the patient a. The evaluation of the past and present health state of each body system 8. Which finding is considered to be subjective? a. Temperature of 101.2°F b. Pulse rate of 96 beats/min c. Measured weight loss of 20 pounds since the previous measurement d. Pain lasting 2 hours d. Pain lasting 2 hours 9. When taking a health history for a child, what information, in addition to that for an adult, is usually obtained? a. Coping and stress management b. A review of immunizations received c. Environmental hazards d. Hospitalization history b. A review of immunizations received 10. Functional assessment measures how a person manages day-to-day activities. The impact of adoption on the daily activities of a child is referred to as: a. Developmental history. b. Instrumental activities of daily living. c. Reason for seeking care. d. Interpersonal relationship assessment. d. Interpersonal relationship assessment. 11. Which two sections of the child's health history become separate sections because of their importance to the child's current health status? a. Play activities and rest patterns b. Prenatal and postnatal status c. Developmental and nutritional history d. Accidents, injuries, and immunizations c. Developmental and nutritional history 12. Which statement best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and examiner b. To provide a form for obtaining the patient's biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patient's past and present health d. To provide a database of subjective information about the patient's past and present health 13. While assessing a man for allergies, he states he is allergic to penicillin. Which response is best? a. "Are you allergic to any other drugs?" b. "How often have you received penicillin?" c. "I'll write your allergy on your chart so you won't receive any." d. "Please describe what happens to you when you take penicillin." d. "Please describe what happens to you when you take penicillin." 1. Although a full mental status examination may not be required, you must be aware of the 4 main headings of the assessment while performing the interview and physical examination. These headings are: a. Mood, affect, consciousness, and orientation. b. Memory, attention, thought content, and perceptions. c. Language, orientation, attention, and abstract reasoning. d. Appearance, behavior, cognition, and thought process. d. Appearance, behavior, cognition, and thought process. 2. Select the finding that most accurately describes appearance of a patient. a. Tense posture and restless activity. Clothing clean but not appropriate for season (e.g., patient wearing T-shirt and shorts in cold weather). b. Oriented × 3. Affect appropriate for circumstances. c. Alert and responds to verbal stimuli. Tearful when diagnosis discussed. d. Laughing inappropriately, oriented × 3. a. Tense posture and restless activity. Clothing clean but not appropriate for season (e.g., patient wearing T-shirt and shorts in cold weather). 3. You are assessing short-term cognitive function. Which assessment shows the ability to lay down new memories? a. Noting whether the patient completes a thought without wandering b. A test of general knowledge c. A description of past medical history d. Use of the Four Unrelated Words Test d. Use of the Four Unrelated Words Test 4. You are preparing the discharge plan for a patient with aphasia. What assessment should you include in the plan? a. Ask the patient to calculate serial 7s. b. Ask the patient to name his or her grandchildren and their birthdays. c. Ask the patient to demonstrate word comprehension by naming articles in the room or on the body as you point to them. d. Ask the patient to interpret a proverb. c. Ask the patient to demonstrate word comprehension by naming articles in the room or on the body as you point to them. 5. During an interview with a patient diagnosed with a seizure disorder, the patient states, "I plan to be an airline pilot." If the patient continues to have this as a career goal after teaching regarding seizure disorders has been provided, you might question the patient's: a. Thought processes. b. Judgment. c. Attention span. d. Recent memory. b. Judgment. 6. On a patient's second day in an acute care hospital, the patient complains about the "bugs" on the bed. The bed is clean. This would be an example of altered: a. Thought processes. b. Orientation. c. Perception. d. Higher intellectual function. c. Perception. 7. One way to assess cognitive function and to screen dementia is with: a. The Proverb Interpretation Test b. The Mini-Cog c. The Denver II d. The Older Adult Behavioral Checklist b. The Mini-Cog 8. A major characteristic of dementia is: a. Impairment of short- and long-term memory. b. Hallucinations. c. Sudden onset of symptoms. d. Substance-induced. a. Impairment of short- and long-term memory. 9. What statement is an example of a patient with dysarthria? a. When asked a question, the patient responds fluently but uses words incorrectly or makes up words so that speech may be incomprehensible. b. The word choice and grammar are appropriate, but the sounds are distorted so speech is unintelligible. c. The pitch and volume of words are difficult and the voice may be hoarse, but language is intact. d. Comprehension is intact but there is difficulty in expressing thoughts, with nouns and verbs being the dominant word choices. b. The word choice and grammar are appropriate, but the sounds are distorted so speech is unintelligible. 10. You are leading a discussion of the planned activities for the day at an adult living center and state, "We will be having snacks at 9:30 and lunch will be at noon." One of the participants responds in a very monotone manner, "Snacks at 9:30, lunch at noon, snacks at 9:30, lunch at noon." This patient is exhibiting signs of: a. Echolalia. b. Confabulation. c. Flight of ideas. d. Neologisms. a. Echolalia. 11. You are performing a mental status examination. Which assessments would be most appropriate? a. Examining the patient's EEG b. Observing the patient as he or she takes an IQ test c. Observing the patient and inferring health or dysfunction d. Examining the patient's response to a specific set of questions c. Observing the patient and inferring health or dysfunction 12. When assessing mental status in children, what statement is true? a. All aspects of mental status in children are interrelated. b. Children are highly labile and unstable until the age of 2. c. Children's mental status is largely a function of their parents' level of functioning until the age of 7. d. A child's mental status is impossible to assess until the child develops the ability to concentrate. a. All aspects of mental status in children are interrelated. 13. You are assessing a 75-year-old man. What is an expected finding? a. He will have no decrease in any of his abilities, including response time. b. He will have difficulty on tests of remote memory because this typically decreases with age. c. It may take him a little longer to respond but his general knowledge and abilities should not have declined. d. He will have had a decrease in his response time due to language loss and a decrease in general knowledge. c. It may take him a little longer to respond but his general knowledge and abilities should not have declined. 14. What is a priority assessment for aging adults? a. Phobias b. General intelligence c. Irrational thinking patterns d. Sensory perceptive abilities d. Sensory perceptive abilities 1. During the assessment, which part of the hand is best for detecting vibration? a. Fingertips b. Index finger and thumb in opposition c. Dorsum of the hand d. Ulnar surface of the hand d. Ulnar surface of the hand 2. When performing indirect percussion, the stationary finger is struck: a. At the ulnar surface. b. At the middle joint. c. At the distal interphalangeal joint. d. Wherever it is in contact with the skin. c. At the distal interphalangeal joint. 3. The best description of the pitch of a sound wave obtained by percussion is: a. The intensity of the sound b. The number of vibrations per second c. The length of time the note lingers d. The overtones of the note b. The number of vibrations per second 4. The bell of the stethoscope is used: a. For soft, low-pitched sounds b. For high-pitched sounds c. To hold firmly against the skin d. To magnify sound a. For soft, low-pitched sounds 5. The ophthalmoscope has 5 apertures. Which aperture is used to assess the eyes of a patient with undilated pupils? a. Grid b. Slit c. Small d. Large c. Small 6. At the conclusion of the patient examination, the examiner should: a. Document findings before leaving the examining room. b. Have findings confirmed by another practitioner. c. Relate objective findings to the subjective findings for accuracy. d. Summarize findings to the patient. d. Summarize findings to the patient. 7. When the examiner enters the examining room, the infant patient is asleep. Which assessment should the examiner perform next? a. Height and weight b. Blood pressure c. Heart, lung, and abdomen d. Temperature c. Heart, lung, and abdomen 8. The sequence of an examination changes from beginning with the thorax to that of head to toe when the patient is in what age category? a. The infant b. The preschool child c. The school-age child d. The adolescent c. The school-age child 9. When inspecting the ear canal of a patient, the examiner chooses which speculum for the otoscope? a. A short, broad one b. The narrowest for a child c. The longest for an adult d. The largest that will fit d. the largest that will fit 10. For a health assessment, which assessment technique will you use first? a. Palpation b. Inspection c. Percussion d. Auscultation b. inspection 11. To assess a patient's abdomen by palpation, how should the nurse proceed? a. Avoid palpation of reported "tender" areas because this may cause the patient pain. b. Quickly palpate a tender area to avoid any discomfort that the patient may experience. c. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. 1. The 4 areas to consider during the general survey include: a. Ethnicity, gender, age, and socioeconomic status b. Physical appearance, gender, ethnicity, and affect c. Dress, affect, nonverbal behavior, and mobility d. Physical appearance, body structure, mobility, and behavior d. Physical appearance, body structure, mobility, and behavior 2. You are assessing a patient's gait. What do you expect to find? a. Gait is varied, depending on the height of the person. b. Gait is equal to the length of the arm. c. Gait is as wide as the shoulder width. d. Gait is half the height of the person. c. Gait is as wide as the shoulder width. 3. An 18-month-old child is brought into the clinic for a health screening visit. To assess the height of the child: a. Use a tape measure. b. Use a horizontal measuring board. c. Have the child stand on the upright scale. d. Measure arm span to estimate height. b. Use a horizontal measuring board. 4. Which changes in head circumference measurements in relation to chest measurements will occur from infancy through early childhood? a. A newborn's head should be approximately 5 cm larger than the chest circumference, but by age 2, they should be equal. b. The chest grows at a faster rate than the cranium, but at age 1, the measurements will be the same, and after age 2, the chest should be approximately 5 cm larger. c. The newborn's head will be 2 cm larger than the chest circumference, but between 6 months and 2 years, they will be about the same. d. The head and chest circumferences should be very similar, but between 6 months and 2 years, the chest size will increase and remain that way. c. The newborn's head will be 2 cm larger than the chest circumference, but between 6 months and 2 years, they will be about the same. 5. Which changes regarding height and weight occur during the 80s and 90s? a. Both increase. b. Weight increases, and height decreases. c. Both decrease. d. Both remain the same as during the 70s. c. Both decrease 6. During an initial home visit, the patient's temperature is noted to be 97.4°F. How would you interpret this? a. It cannot be evaluated without knowledge of the person's age. b. It is below normal. The person should be assessed for possible hypothermia. c. It should be retaken by the rectal route, because this best reflects core body temperature. d. It should be reevaluated at the next visit before a decision is made. a. It cannot be evaluated without knowledge of the person's age. 7. Select the best description of an accurate assessment of a patient's pulse. a. Count for 15 seconds if the pulse is regular. b. Begin counting with zero; count for 30 seconds. c. Count for 30 seconds and multiply by 2 for all cases. d. Count for 1 full minute; begin counting with zero. b. Begin counting with zero; count for 30 seconds. 8. After assessing the patient's pulse, the practitioner determines it to be "normal." This would be recorded as: a. 3+. b. 2+. c. 1+. d. 0. b. 2+. 9. Select the best description of an accurate assessment of a patients' respirations. a. Count for a full minute before taking the pulse. b. Count for 15 seconds and multiply by 4. c. Count after informing the patient where you are in the assessment process. d. Count for 30 seconds after pulse assessment. d. Count for 30 seconds after pulse assessment. 10. Pulse pressure is described as: a. The difference between the systolic and diastolic pressure b. A reflection of the viscosity of the blood c. Another way to express the systolic pressure d. A measure of vasoconstriction a. The difference between the systolic and diastolic pressure 11. The examiner suspects a patient has coarctation of the aorta. Which assessment finding supports this suspicion? a. The thigh pressure is higher than in the arm. b. The thigh pressure is equal to that in the arm. c. The thigh pressure is unrelated to the arm pressure. There is no constant relationship; findings are highly individual. d. The pressure is lower than in the arm. d. The pressure is lower than in the arm. 12. Mean arterial pressure is: a. The arithmetic average of systolic and diastolic pressures b. The driving force of blood during systole c. Diastolic pressure plus one third of the pulse pressure d. Corresponding to phase III Korotkoff c. Diastolic pressure plus one third of the pulse pressure 13. Why is it important to match the appropriate size of blood pressure cuff to the person's arm and shape and not to the person's age? a. Using a cuff that is too narrow will give a false reading that is high. b. Using a cuff that is too wide will give a false reading that is low. c. Using a cuff that is too narrow will give a false reading that is low. d. Using a cuff that is too wide will give a false reading that is high. a. Using a cuff that is too narrow will give a false reading that is high. 14. A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should you proceed with the examination? a. Take the blood pressure in both arms and thighs. b. Ask the person to walk a few paces and then take the blood pressure. c. Record the blood pressure in the lying, sitting, and standing positions. d. Record the blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure. c. Record the blood pressure in the lying, sitting, and standing positions. 15. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? a. The pulse is more difficult to palpate because of the stiffness of the blood vessels. b. An increased respiratory rate and a shallower inspiratory phase are possible findings. c. A decreased pulse pressure occurs from changes in systolic and diastolic blood pressures. d. Changes in the body's temperature regulatory mechanism leave the aging person more likely to develop a fever. b. An increased respiratory rate and a shallower inspiratory phase are possible findings. 1. At which phase does the individual become aware of a painful sensation? a. Modulation b. Transduction c. Perception d. Transmission c. Perception 2. While taking a history, the patient describes a burning, painful sensation that moves around the toes and bottoms of the feet. These symptoms suggest: a. Nociceptive pain b. Neuropathic pain c. Visceral pain d. Muscular pain b. Neuropathic pain 3. During the physical examination, your patient is diaphoretic and pale and complains of dull pain in the LUQ of the abdomen. This is what type of pain? a. Cutaneous pain b. Somatic pain c. Visceral pain d. Psychogenic pain c. Visceral pain 4. While caring for a preterm infant, you are aware that: a. Inhibitory neurotransmitters are in sufficient supply by 15 weeks' gestation. b. The fetus has less capacity to feel pain. c. Repetitive blood draws have minimal long-term consequences. d. The preterm infant is more sensitive to painful stimuli. d. The preterm infant is more sensitive to painful stimuli. 5. The most reliable indicator of pain in the adult is: a. The degree of physical functioning b. Nonverbal behaviors c. The MRI findings d. The patient's self-report d. The patient's self-report 6. While examining the broken arm of a 4-year-old boy, select the appropriate assessment tool to evaluate his pain status. a. 0 to 10 numeric rating scale b. Wong-Baker scale c. Simple descriptor scale d. 0 to 5 numeric rating scale b. Wong-Baker scale 7. Normal age-related finding in the lower extremities of an 80-year-old woman would be: a. Crepitus b. Joint swelling c. Diminished strength bilaterally d. Unilateral muscle atrophy c. Diminished strength bilaterally 8. A patient presents with acute pain of the abdomen. After the initial examination, how would you proceed? a. Withhold analgesic until diagnostic testing is completed. b. Give pain medications as ordered. c. Withhold analgesic until pain subsides. d. Determine what type of pain it is and proceed accordingly. b. Give pain medications as ordered. 9. For older adult postoperative patients, poorly controlled acute pain places them at higher risk for: a. Atelectasis b. Increased myocardial oxygen demand c. Impaired wound healing d. All of the above d. All of the above 10. A 30-year-old woman reports having persistent intense pain in her right arm related to trauma sustained from a car accident 5 months ago. She states that the slightest touch or clothing can exacerbate the pain. This report is suggestive of: a. Referred pain b. Psychogenic pain c. Complex regional pain I d. Cutaneous pain c. Complex regional pain I 11. CRIES is an appropriate pain assessment tool for: a. Cognitively impaired older adults b. Children ages 2 to 8 years c. Infants d. Preterm and term neonates d. Preterm and term neonates 12. Pain issues should be anticipated in a cognitively impaired older adult with a history of: a. Constipation b. Peripheral vascular disease c. COPD d. Parkinson disease b. Peripheral vascular disease 13. Pain in the aging adult is considered to be: a. Part of the normal degenerative process b. Perceived to a lesser degree c. An expected finding d. Unrelated to the aging process d. Unrelated to the aging process 14. Which is considered a common physiologic change that occurs with pain? a. Polyuria b. Hyperventilation c. Hyperactive bowel sounds d. Tachycardia d. Tachycardia 15. A patient is requesting pain medication and expresses a pain level of 9/10; however, the patient is up and smiling. How should you proceed? a. Complete a full physical examination. b. Check to see when the patient last received the pain medication and administer it if the time is appropriate. c. Call the provider and suggest a substance abuse consult. d. Use therapeutic communication techniques to determine the patient's current prescription drug use. d. Use therapeutic communication techniques to determine the patient's current prescription drug use. 1. The balance between nutrient intake and nutrient requirements is described as: a. Undernutrition b. Malnutrition c. Nutritional status d. Overnutrition c. Nutritional status 2. You are providing health promotion teaching for a newly pregnant woman, and recommend which of the following weight gain parameters for a healthy pregnancy? a. 25 to 35 pounds b. 28 to 40 pounds c. 15 to 25 pounds d. The recommendation depends on the BMI of the mother at the start of the pregnancy. d. The recommendation depends on the BMI of the mother at the start of the pregnancy. 3. Which is a normal expected change with aging? a. Increase in energy needs b. Increase in body water c. Decrease in height d. Increase in AP diameter of the chest c. Decrease in height 4. You obtain which data when screening patients for nutritional status? a. Temperature, pulse, and respiration b. Blood pressure and genogram c. Weight and nutrition intake history d. Serum creatinine levels c. Weight and nutrition intake history 5. A 24-hour recall of dietary intake is used: a. As an anthropometric measure of calories consumed b. As a questionnaire or interview of everything eaten within the last 24 hours c. As the same as a food frequency questionnaire d. As a form of food diary b. As a questionnaire or interview of everything eaten within the last 24 hours 6. Mary, a 15-year-old, has come for a school physical. During the interview, you learn that menarche has not occurred. The BMI is 17. You suspect: a. Nutritional deficiency b. Alcohol intake c. Smoking history d. Possible elevated blood sugar a. Nutritional deficiency 7. Which older adult is at lowest risk for alteration in nutritional status? a. 80-year-old widow who lives alone b. 65-year-old widower who visits a senior center with a meal program 5 days per week c. 70-year-old person with poor dentition who lives with a son d. 73-year-old couple with low income and no transportation b. 65-year-old widower who visits a senior center with a meal program 5 days per week 8. The examiner is completing an initial assessment for a patient admitted to a long-term care facility. The patient is unable to stand for a measurement of height. To obtain this important anthropometric information, the examiner would: a. Measure the waist-to-hip circumference. b. Estimate the body mass index. c. Measure arm span. d. Obtain a mid-upper arm muscle circumference to estimate skeletal muscle reserve. c. Measure arm span. 9. Which assessment finding indicates a patient at nutrition risk? a. BMI = 24 kg/m2 b. Waist circumference at 43 inches c. Current weight = 200 lb d. BMI = 19 kg/m2 b. Waist circumference at 43 inches 10. Marasmus is often characterized by: a. Severely depleted visceral proteins b. Elevated triglycerides c. Hyperglycemia d. Low weight for height d. Low weight for height 11. Which BMI category in adults is indicative of obesity? a. 18.5 to 24.9 kg/m2 b. 25.0 to 29.9 kg/m2 c. 30.0 to 39.9 kg/m2 d. <18.5 kg/m2 c. 30.0 to 39.9 kg/m2 12. Why should you ask about the use of medications when assessing a patient's nutritional status? a. Medication allergies are on the rise and are a major health concern. b. Many drugs can interact with nutrients and impair their digestion, absorption, metabolism, or uptake. c. Patients readily discuss their daily use of vitamin and mineral supplements when asked. d. The use of anabolic steroids can reduce muscle size and physical performance. b. Many drugs can interact with nutrients and impair their digestion, absorption, metabolism, or uptake.