Fundamentals EAQs Health Assessment
Exam Questions With Correct Answers
What are physiologic symptoms assessed in a client with sleep
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deprivation? Select all that apply. - CORRECT ANSWER✔✔-1
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Correct: Ptosis and blurred vision
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2
Agitation and hyperactivity
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3
Confusion and disorientation | |
4
Increased sensitivity to pain
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5
Correct: Decreased auditory alertness
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R: Ptosis may result from a loss of elasticity of the eyelids, which is a
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physiologic symptom of sleep deprivation. Decreased auditory alertness
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and blurred vision are also physiologic symptoms of sleep deprivation.
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Agitation, hyperactivity, confusion, disorientation, and increased
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sensitivity to pain are psychologic symptoms of sleep deprivation.
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,A nurse notices cyanosis in a client with heart disease. Which site would
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the nurse assess to confirm cyanosis? - CORRECT ANSWER✔✔-Correct1
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Lips
2
Sclera
3
Conjunctiva
4
Mucus membrane |
R: The lips and nail beds are the best sites to assess for cyanosis. The
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sclera and mucous membrane are assessed in jaundice. The conjunctiva
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is assessed for the presence of pallor.
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Which feature is characteristic of a risk nursing diagnosis? - CORRECT
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ANSWER✔✔-Correct1
The diagnosis does not have related factors.
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2
The diagnosis can be used in any health state.
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3
The defining characteristics support the diagnostic judgment.
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4
,The defining characteristics are supported by a client's readiness.
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R: A risk nursing diagnosis describes human responses to health
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conditions that may develop in a vulnerable individual, family, or
| | | | | | | | | |
community. Risk diagnoses do not have related factors or defining
| | | | | | | | | |
characteristics because they have not occurred yet. A risk diagnosis has| | | | | | | | | | |
risk factors that help the nurse plan preventive measures. A health
| | | | | | | | | | |
promotion nursing diagnosis can be applied to any individual with a
| | | | | | | | | | |
desire to enhance health behaviors in any health state. An actual
| | | | | | | | | | |
diagnosis is formed when the defining characteristics support the
| | | | | | | | |
diagnostic judgment. There must be sufficient nursing assessment data
| | | | | | | | |
to establish an actual diagnosis. A health promotion nursing diagnosis is
| | | | | | | | | | |
a clinical judgment of an individual's readiness to increase well-being.
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Which client assessment finding should the nurse document as
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subjective data? - CORRECT ANSWER✔✔-1 | | | |
Blood pressure 120/82 beats/min
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Correct2
Pain rating of 5| | |
3
Potassium 4.0 mEq | |
4
Pulse oximetry reading of 96%
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, R: Subjective data are obtained directly from a client. Subjective data
| | | | | | | | | | |
are often recorded as direct quotations that reflect the client's feelings
| | | | | | | | | | |
about a situation. Vital signs, laboratory results, and pulse oximetry are
| | | | | | | | | | |
examples of objective data.Test-Taking Tip: Identifying content and what
| | | | | | | |
is being asked about that content is critical to your choosing the correct
| | | | | | | | | | | | | |
response. Be alert for words in the stem of the item that are the same
| | | | | | | | | | | | | | |
or similar in nature to those in one or two of the options. Example: If
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the item relates to and identifies stroke rehabilitation as its focus and
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only one of the options contains the word stroke in relation to
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rehabilitation, you are safe in identifying this choice as the correct
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response.
The nurse noticed the breathing rate as regular and slow while assessing
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a client for respiration. What could be the condition of the client? -
| | | | | | | | | | | | | |
CORRECT ANSWER✔✔-1 |
Apnea
Correct2
Bradypnea
3
Tachypnea
4
Hyperpnea
R: In bradypnea the breathing rate is regular, but it is abnormally slow.
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Respirations cease for several seconds in apnea. The rate of breathing is
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Exam Questions With Correct Answers
What are physiologic symptoms assessed in a client with sleep
| | | | | | | | | |
deprivation? Select all that apply. - CORRECT ANSWER✔✔-1
| | | | | | |
Correct: Ptosis and blurred vision
| | | |
2
Agitation and hyperactivity
| |
3
Confusion and disorientation | |
4
Increased sensitivity to pain
| | |
5
Correct: Decreased auditory alertness
| | |
R: Ptosis may result from a loss of elasticity of the eyelids, which is a
| | | | | | | | | | | | | | |
physiologic symptom of sleep deprivation. Decreased auditory alertness
| | | | | | |
and blurred vision are also physiologic symptoms of sleep deprivation.
| | | | | | | | | | |
Agitation, hyperactivity, confusion, disorientation, and increased
| | | | | |
sensitivity to pain are psychologic symptoms of sleep deprivation.
| | | | | | | |
,A nurse notices cyanosis in a client with heart disease. Which site would
| | | | | | | | | | | |
the nurse assess to confirm cyanosis? - CORRECT ANSWER✔✔-Correct1
| | | | | | | | |
Lips
2
Sclera
3
Conjunctiva
4
Mucus membrane |
R: The lips and nail beds are the best sites to assess for cyanosis. The
| | | | | | | | | | | | | | |
sclera and mucous membrane are assessed in jaundice. The conjunctiva
| | | | | | | | | |
is assessed for the presence of pallor.
| | | | | |
Which feature is characteristic of a risk nursing diagnosis? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-Correct1
The diagnosis does not have related factors.
| | | | | |
2
The diagnosis can be used in any health state.
| | | | | | | |
3
The defining characteristics support the diagnostic judgment.
| | | | | |
4
,The defining characteristics are supported by a client's readiness.
| | | | | | | |
R: A risk nursing diagnosis describes human responses to health
| | | | | | | | | |
conditions that may develop in a vulnerable individual, family, or
| | | | | | | | | |
community. Risk diagnoses do not have related factors or defining
| | | | | | | | | |
characteristics because they have not occurred yet. A risk diagnosis has| | | | | | | | | | |
risk factors that help the nurse plan preventive measures. A health
| | | | | | | | | | |
promotion nursing diagnosis can be applied to any individual with a
| | | | | | | | | | |
desire to enhance health behaviors in any health state. An actual
| | | | | | | | | | |
diagnosis is formed when the defining characteristics support the
| | | | | | | | |
diagnostic judgment. There must be sufficient nursing assessment data
| | | | | | | | |
to establish an actual diagnosis. A health promotion nursing diagnosis is
| | | | | | | | | | |
a clinical judgment of an individual's readiness to increase well-being.
| | | | | | | | |
Which client assessment finding should the nurse document as
| | | | | | | | |
subjective data? - CORRECT ANSWER✔✔-1 | | | |
Blood pressure 120/82 beats/min
| | |
Correct2
Pain rating of 5| | |
3
Potassium 4.0 mEq | |
4
Pulse oximetry reading of 96%
| | | |
, R: Subjective data are obtained directly from a client. Subjective data
| | | | | | | | | | |
are often recorded as direct quotations that reflect the client's feelings
| | | | | | | | | | |
about a situation. Vital signs, laboratory results, and pulse oximetry are
| | | | | | | | | | |
examples of objective data.Test-Taking Tip: Identifying content and what
| | | | | | | |
is being asked about that content is critical to your choosing the correct
| | | | | | | | | | | | | |
response. Be alert for words in the stem of the item that are the same
| | | | | | | | | | | | | | |
or similar in nature to those in one or two of the options. Example: If
| | | | | | | | | | | | | | |
the item relates to and identifies stroke rehabilitation as its focus and
| | | | | | | | | | | |
only one of the options contains the word stroke in relation to
| | | | | | | | | | | |
rehabilitation, you are safe in identifying this choice as the correct
| | | | | | | | | | |
response.
The nurse noticed the breathing rate as regular and slow while assessing
| | | | | | | | | | |
a client for respiration. What could be the condition of the client? -
| | | | | | | | | | | | | |
CORRECT ANSWER✔✔-1 |
Apnea
Correct2
Bradypnea
3
Tachypnea
4
Hyperpnea
R: In bradypnea the breathing rate is regular, but it is abnormally slow.
| | | | | | | | | | | | |
Respirations cease for several seconds in apnea. The rate of breathing is
| | | | | | | | | | | |
