NUR631-ADVANCED HEALTH ASSESSMENT TEST 1 LATEST 2024/2025 QUESTIONS WITH 100% CORRECT ANSWERS GRADED A+

NUR631-ADVANCED HEALTH ASSESSMENT TEST 1 LATEST 2024/2025 QUESTIONS WITH 100% CORRECT ANSWERS GRADED A+ “What is the function of the goblet cells of the lungs? A. To enable the exchange of gases B. To sweep away particulate matter C. To provide space for gas exchange D. To entrap small particulate matter - CORRECT ANSWER D" "What assessment finding will the nurse document in a patient with pneumonia? A. A smooth chest expansion B. A lag in the chest expansion C. A palpable grating sensation D. A slight inspiratory variation - CORRECT ANSWER B" "Increased tactile fremitus would be evident in an individual who has which of the following conditions? A. Emphysema B. Pneumonia C. Crepitus D. Pneumothorax - CORRECT ANSWER B" "A common clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD) is :A. periodic breathing patterns .B. pursed-lip breathing. C. unequal chest expansion .D. hyperventilation. - CORRECT ANSWER B" "Which of the following is not included in the definition of the thoracic cage? A. Sternum B. Ribs C. Costochondral junction D. Diaphragm - CORRECT ANSWER C" "Inspiration is primarily facilitated by which of the following muscles? A. Diaphragm and rectus abdominis B. Trapezius and sternomastoids C. Internal intercostal and abdominis D. Diaphragm and intercostal - CORRECT ANSWER D" "Which of the following voice sounds would be a normal finding? A. The voice transmission is distinct and sounds close to the ear. B. The "eeeee" sound is clear and sounds like "eeeee." C. The whispered sound is transmitted clearly. D. Whispered "1-2-3" is audible and distinct. - CORRECT ANSWER B" "The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of elderly adults cause: A. hyperventilation. B. spontaneous atelectasis. C. decreased surface area for gas exchange. D. decreased dead space. - CORRECT ANSWER C" "You note a lesion during a skin assessment. Which is the best way to document this finding? A. Raised, irregular lesion the size of a quarter, located on dorsum of left hand B. Open lesion with no drainage or odor, approximately 1/4 inch in diameter C. Pedunculated lesion below left scapula with consistent red color and no drainage or odor D. Dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, with no drainage - CORRECT ANSWER D" "You examine the nail beds of a patient. Which finding indicates a normal angle? A. 60 degrees B. 100 degrees C. 160 degrees D. 180 degrees - CORRECT ANSWER C" "You are assessing capillary refill. The room is warm. Which finding would be considered normal? A. <1 second B. >2 seconds C. 2 to 3 seconds D. Time is not significant as long as color returns - CORRECT ANSWER A" "During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. What is your best response after assessing the areas? A. "These re the result of sun exposure and do not require treatment." B. "These are related to exposure to the sun, they may become cancerous." C. "These are the skin tags that occur with agin, No treatment is required. "D. "I'm glad you brought this to my attention. I will arrange for a biopsy." - CORRECT ANSWER A" "An area of thin shiny skin with decreased visibility of normal skin markings is most likely: A. Lichenification B. Plaque C. Atrophy D. Keloid - CORRECT ANSWER C" "Flattening of the angle between the nail and its base is: A. Found in subacute bacterial endocarditis B. A description of spoon-shaped nails C. Related to calcium deficiency D. Described as clubbing - CORRECT ANSWER D" "A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a: A. Linear lesion B. Clustered lesion C. Annular lesion D. Gyrate lesion - CORRECT ANSWER C" "The "A" in the ABCDE rule for skin cancer stands for: A. Accuracy B. Appearance C. Asymmetry D. Attenuated - CORRECT ANSWER C" "A risk factor for melanoma is: A. Brown eyes B. Darkly pigmented skin C. Skin that freckles or burns before tanning D. Use of sunscreen products - CORRECT ANSWER C" "Herpes zoster infection (shingles) is characterized by :A. A bacterial cause B. Lesion on only one side of the body; does not cross midline C. Absence of pain or edema D. Pustular, umbilicated lesion - CORRECT ANSWER B" "The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk? a.29-year-old woman whose waist measures 33 inches and hips measure 36 inches b.32-year-old man whose waist measures 34 inches and hips measure 36 inches c.38-year-old man whose waist measures 35 inches and hips measure 38 inches d.46-year-old woman whose waist measures 30 inches and hips measure 38 inches - CORRECT ANSWER A" "A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? a.The risks of undernutrition should be included. b.Offer methods to reduce the stress in her life. c.Provide information regarding a diet low in saturated fat. d.This condition is hereditary; she can do nothing to change the levels - CORRECT ANSWER C" "In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? a.Increase in hair growth b.Inadequate nutrient food intake c.Weight 10% to 20% over ideal d.Sore, inflamed buccal cavity - CORRECT ANSWER B" "A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find? a.Poor skin turgor b.Decreased serum albumin c.Increased lymphocyte count d.Triceps skinfold less than standard - CORRECT ANSWER B" "The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: a.Slowed gastrointestinal motility. b.Hyperstimulation of the salivary glands. c.Increased sensitivity to spicy and aromatic foods. d.Decreased gastrointestinal absorption causing esophageal reflux. - CORRECT ANSWER A" "Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? a.Decreasing the amount of carbohydrates to prevent lean muscle catabolism b.Increasing the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis c.Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass d.Increasing the number of calories she is eating because of the increased energy needs of the older adult - CORRECT ANSWER C" "The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a.Ask the patient to take deep breaths to relax the abdominal musculature .b.Consider this finding as normal, and proceed with the abdominal assessment .c.Increase the amount of strength used when attempting to percuss over the abdomen. d.Decrease the amount of strength used when attempting to percuss over the abdomen. - CORRECT ANSWER C" "The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should :a.Palpate over the area for increased pain and tenderness. b.Ask the child to take shallow breaths, and percuss over the area again. c.Immediately refer the child because of an increased amount of air in the lungs. d.Consider this finding as normal for a child this age, and proceed with the examination - CORRECT ANSWER D" "A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a.Count the patients respirations. b.Bilaterally percuss the thorax, noting any differences in percussion tones. c.Call for a chest x-ray study, and wait for the results before beginning an assessment .d.Inspect the thorax for any new masses and bleeding associated with respirations. - CORRECT ANSWER B" "The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a.Slope of the earpieces should point posteriorly (toward the occiput) .b.Although the stethoscope does not magnify sound, it does block out extraneous room noise .c.Fit and quality of the stethoscope are not as important as its ability to magnify sound. d.Ideal tubing length should be 22 inches to dampen the distortion of sound. - CORRECT ANSWER B" "The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a.Is used to listen for high-pitched sounds. b.Is used to listen for low-pitched sounds. c.Should be lightly held against the persons skin to block out low-pitched sounds .d.Should be lightly held against the persons skin to listen for extra heart sounds and murmurs - CORRECT ANSWER A" "Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a.Warm the endpiece of the stethoscope by placing it in warm water. b.Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c.Ensure that the bell side of the stethoscope is turned to the on position. d.Check the temperature of the room, and offer blankets to the patient if he or she feels cold - CORRECT ANSWER D" "The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a.Palpation b.Inspection c.Percussion d.Auscultation - CORRECT ANSWER A" "The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope :a.Is often used to direct light onto the sinuses. b.Uses a short, broad speculum to help visualize the ear. c.Is used to examine the structures of the internal ear. d.Directs light into the ear canal and onto the tympanic membrane. - CORRECT ANSWER D" "An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a.Using the large full circle of light when assessing pupils that are not dilated b.Rotating the lens selector dial to the black numbers to compensate for astigmatism c.Using the grid on the lens aperture dial to visualize the external structures of the eye d.Rotating the lens selector dial to bring the object into focus - CORRECT ANSWER D" "The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a.Auscultate over the area with a fetoscope. b.Use a goniometer to measure the pulsations. c.Use a Doppler device to check for pulsations over the area. d.Check for the presence of pulsations with a stethoscope. - CORRECT ANSWER C" "A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a.Ask the parent to place the child on the examining table. b.Have the parent remove all of the childs clothing before the examination. c.Allow the child to keep a security object such as a toy or blanket during the examination. d.Initially focus the interactions on the child, essentially ignoring the parent until the childs trust has been obtained - CORRECT ANSWER C" "The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurses technique is most accurate? a.Asking questions enhances the childs autonomy b.Asking the child for permission helps develop a sense of trust c.This question is an appropriate statement because children at this age like to have choices d.Children at this age like to say, No. The examiner should not offer a choice when no choice is available - CORRECT ANSWER D" "With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on the penlight? a.Infant b.Preschool child c.School-age child d.Adolescent - CORRECT ANSWER B" "The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a.Explain the procedures in detail to alleviate the childs anxiety b.Give the child feedback and reassurance during the examination. c.Do not ask the child to remove his or her clothes because children at this age are usually very private .d.Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdome - CORRECT ANSWER B" "When examining a 16-year-old male teenager, the nurse should: a.Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b.Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c.Talk to him the same manner as one would talk to a younger child because a teens level of understanding may not match his or her speech. d.Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. - CORRECT ANSWER D" "During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a."How do you feel today?" b."Would you please repeat the following words? "c."Have these medications had any effect on your pain?" d."Has this pain affected your ability to get dressed by yourself?" - CORRECT ANSWER A" "The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a.Administer the FACT test. b.Ask him to describe his first job. c.Give him the Four Unrelated Words Test. d.Ask him to describe what television show he was watching before coming to the clinic. - CORRECT ANSWER C" "A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. a.Invent; within 5 minutes b.Invent; within 30 seconds c.Recall; after a 30-minute delay d.Recall; after a 60-minute delay - CORRECT ANSWER C" "During a mental status assessment, which question by the nurse would best assess a person's judgment? a."Do you feel that you are being watched, followed, or controlled? "b."Tell me what you plan to do once you are discharged from the hospital." c."What does the statement, 'People in glass houses shouldn't throw stones,' mean to you? "d."What would you do if you found a stamped, addressed envelope lying on the sidewalk?" - CORRECT ANSWER B" "Which of these individuals would the nurse consider at highest risk for a suicide attempt? a.Man who jokes about death b.Woman who, during a past episode of major depression, attempted suicide c.Adolescent who just broke up with her boyfriend and states that she would like to kill herself d.Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun - CORRECT ANSWER D" "The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a.Mental status assessment diagnoses specific psychiatric disorders .b.Mental disorders occur in response to everyday life stressors. c.Mental status functioning is inferred through the assessment of an individual's behaviors .d.Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds). - CORRECT ANSWER C" "A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? a."How do you usually feel? Is this normal behavior for you? "b."I am going to say four words. In a few minutes, I will ask you to recall them." c."Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" d."Pick up the pencil in your left hand, move it to your right hand, and place it on the table." - CORRECT ANSWER D" "The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? a."Please count backward from 100 by seven. "b."I will name three items and ask you to repeat them in a few minutes ."c."Please point to articles in the room and parts of the body as I name them. "d."What would you do if you found a stamped, addressed envelope on the sidewalk? - CORRECT ANSWER C" "A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? a."Do you have a weapon?" b."How do other people treat you? "c."Are you feeling so hopeless that you feel like hurting yourself now?" d."People often feel hopeless, but the feelings resolve within a few weeks." - CORRECT ANSWER C" "The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? a.Scores below 30 indicate cognitive impairment. b.The MMSE is a good tool to evaluate mood and thought processes. c.This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d.The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time. - CORRECT ANSWER C" "The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a.Global b.Broca's c.Dysphonic d.Wernicke's - CORRECT ANSWER A" "A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: a.Blocking b.Clanging c.Echolalia d.Neologism - CORRECT ANSWER B" "During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a.Social phobia b.Compulsive disorder c.Generalized anxiety disorder d.Posttraumatic stress disorder - CORRECT ANSWER B" "The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a.Cognitive impairment b.Amnesia c.Delirium d.Attention-deficit disorder - CORRECT ANSWER A" "In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. "This has been a difficult year for you." b. "I don't know how anyone could handle that much stress in 1 year!" c. "What did you do to cope with the loss of both your husband and mother?" d. "That is a lot of stress; now let's go on to the next section of your history." - CORRECT ANSWER C" "In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patient's reliability .b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious - CORRECT ANSWER B" "The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. "Maybe she is just teething." b. "I will check her ear for an ear infection." c. "Are you sure she is really having pain?" d. "Describe what she is doing to indicate she is having pain." - CORRECT ANSWER D" "During an assessment of a patient's family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a person's near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patient's family members up to five generations back d. Description of the health of a person's children and grandchildren - CORRECT ANSWER B" "A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child's birth weight b. Age at which he crawled c. Whether the child has had the measles d. Child's reactions to previous hospitalizations - CORRECT ANSWER D" "As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted. - CORRECT ANSWER B" "In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations .c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities. - CORRECT ANSWER D" "When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care - CORRECT ANSWER C" "The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Obstetric history b. Childhood illnesses c. General health for the past 20 years d. Current health promotion activities - CORRECT ANSWER D" "The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. The questions asked are identical for all ages. b. The interviewer will start incorporating different questions for patients 70 years of age and older. c. Questions that are reflective of the normal effects of aging are added. d. At this age, a review of systems is not necessary—the focus should be on current problems.. - CORRECT ANSWER C" "A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. "Can you tell me what they look like?" b. "Don't worry about it. You are only taking two medications." c. "How long have you been taking each of the pills?" d. "Would you have a family member bring in your medications?" - CORRECT ANSWER D" "The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. "Do you wear glasses?" b. "Are you able to dress yourself? "c. "Do you have any thyroid problems? "d. "How many times a day do you have a bowel movement? - CORRECT ANSWER B" "The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones .c. The functional assessment can identify any problems with memory the individual may be experiencing .d. It helps determine how a person is managing day-to-day activities. - CORRECT ANSWER D" "The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100° F - CORRECT ANSWER A" "A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. "It is a sharp, burning pain in my stomach." b. "I also have the sweats and nausea when I feel this pain." c. "I think this pain is telling me that something bad is wrong with me." d. "This pain happens every time I sit down to use the computer." - CORRECT ANSWER D" "During an assessment, the nurse uses the CAGE test. The patient answers "yes" to two of the questions. What could this be indicating?a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment. - CORRECT ANSWER D" "The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. "Do you believe in God?" b. "Are you a part of any religious or spiritual congregation?" c. "Do you consider yourself to be a religious or spiritual person?" d. "How does your religious faith influence the way you think about your health?" - CORRECT ANSWER B" "The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. "Please stay during the interview; you can answer for her if she does not know the answer." b. "It would help to interview the three of you together." c. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?" d. "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?" - CORRECT ANSWER D" "The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. "Why did you come to the United States?" b. "When did you come to the United States and from what country?" c. "What made you leave your native country?" d. "Are you planning to return to your home?" - CORRECT ANSWER B" "The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. "Where is the headache pain?" b. "Did you have these headaches as a child?" c. "On a scale of 1 to 10, how bad is the pain?" d. "How often do the headaches occur?" e. "What makes the headaches feel better?" f. "Do you have any family history of headaches? - CORRECT ANSWER A C D E" "In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation. - CORRECT ANSWER D" "When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he is ready. b. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains. c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there? d. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time. - CORRECT ANSWER A" "A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: a. Go on, Im listening. b. Fits? Tell me what you mean by this. c. Yes, it can be upsetting when a child has a fit. d. Dont be upset when he has a fit; every 2 year old has fits. - CORRECT ANSWER B" "A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? a. You feel alone. b. You cant believe he left you alone? c. It must be so hard to face this all alone. d. I would be angry, too; raising a child alone is no picnic. - CORRECT ANSWER C" "A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. Mr. K., I know that you are lying. b. Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket. - CORRECT ANSWER D" "The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a.Apologize, because using interpretation can be demeaning for the patient. b.Allow time for the patient to confirm or correct the inference. c.Continue with the interview as though nothing has happened. d.Immediately restate the nurses conclusion on the basis of the patients nonverbal response. - CORRECT ANSWER B" "During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d. It sounds as though you have made your decision. I think it is a good one. - CORRECT ANSWER C" "A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. - CORRECT ANSWER B" "During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer? - CORRECT ANSWER B" "As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d. I can see that you are very upset. Perhaps we should discuss this later. - CORRECT ANSWER A" "A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d. Using blunt language to deal with distasteful topics. - CORRECT ANSWER C" "When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings. - CORRECT ANSWER D" "During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: a. Simply changing positions. b. More comfortable in this position. c. Tired and needs a break from the interview. d. Uncomfortable talking about his sons treatment. - CORRECT ANSWER D" "A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view. - CORRECT ANSWER B" "During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are. - CORRECT ANSWER D" "A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up. - CORRECT ANSWER B" "A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said - CORRECT ANSWER A" "The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read. - CORRECT ANSWER A" "During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d. I can see that you feel sad about this; why dont we talk about something else? - CORRECT ANSWER B" "A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away. - CORRECT ANSWER A" "A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a.The woman is nervous and embarrassed. b.She has something to hide and is ashamed .c.The woman is showing inconsistent verbal and nonverbal behaviors. d.She is showing that she is carefully listening to what the nurse is saying. - CORRECT ANSWER D" "The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. Do you take medicine? b. Do you sterilize the bottles? c. Do you have nausea and vomiting? d. You have been taking your medicine, havent you? - CORRECT ANSWER A" "A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. How is your family? b. How is your job? c. Tell me about your hypertension. d. How has your health been since your last visit? - CORRECT ANSWER D" ". The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? a. This comment is inappropriate because it shows the nurses bias. b. This comment is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times. - CORRECT ANSWER C" "A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department - CORRECT ANSWER A" "During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. b. This question is an innocent search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior. - CORRECT ANSWER A" "The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. Did we forget something? b. Is there anything else you would like to mention? c. I need to go on to the next patient. Ill be back. d. While Im here, lets talk about your upcoming surgery. - CORRECT ANSWER B" "During the interview portion of data collection, the nurse collects __________ data. a. Physical b. Historical c. Objective d. Subjective - CORRECT ANSWER D" "During an interview, the nurse would expect that most of the interview will take place at what distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance - CORRECT ANSWER C" "A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: a. Stop that immediately! b. Oh, you are too funny. Lets keep going with the interview. c. Do you really think I would be interested? d. It makes me uncomfortable when you talk that way. Please stop. - CORRECT ANSWER D" "What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures? a. complete b. focused c. follow up d. emergency - CORRECT ANSWER D" "A nurse precepting a student nurse asks, "What's the most important step in the critical-thinking process?" a. clustering subjective and objective data b. analyzing health data c. using evidence based assessment techniques d. prioritizing health concerns - CORRECT ANSWER C" "An example of subjective data is a. decreased range of motion b. crepitation in left knee joint c. arthritis d. left knee has been swollen and hot for past 3 days - CORRECT ANSWER D" "What type of database is most appropriate for an individual who is admitted to a long-term care facility? a. focused b. complete c. emergency d. follow up - CORRECT ANSWER B" "Which of the following is an example of objective data? a. a sore throat b. an earache c. alert and oriented d. dizziness - CORRECT ANSWER C" "An example of objective data is a. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion. b. a complaint of left knee pain. c. crepitation in the left knee joint. d. left knee has been swollen and hot for the past 3 days. - CORRECT ANSWER C" "Which of the following is an example of subjective data? a. Blood glucose 126 md/dL b. Pain rated at 7 out of 10 c. Heart rate of 76 bpm d. Bruising on lower leg - CORRECT ANSWER B" "A complete database is a. used to collect data rapidly and is often compiled concurrently with lifesaving measures. b. used to evaluate the cause or etiology of disease. c. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. d. used to perform a thorough or comprehensive health history and physical examination. - CORRECT ANSWER D" "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. Impaired gas exchange c. Readiness for enhanced spiritual well-being d. Risk for infection - CORRECT ANSWER B" "Which of the following actions/behaviors in the critical-thinking process are important for the novice nurse to remember? (Select all that apply.) a. disregard initial cues b. Approach assessment with a nonjudgmental attitude c. Cluster associated assessment data d. Perform assessment in whatever manner works for you. e. Avoid making assumptions - CORRECT ANSWER B C E" "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. - CORRECT ANSWER C" "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. d. All subjective and objective data, data gathered from a patient, and the results of any laboratory or diagnostic studies completed. - CORRECT ANSWER D" "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 - CORRECT ANSWER C" "A patient 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 livesaving measures. - CORRECT ANSWER B" "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" - CORRECT ANSWER C" "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 - CORRECT ANSWER A" "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. - CORRECT ANSWER A" "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. - CORRECT ANSWER C" "A patient says she is very nervous and nauseated, and she feels as if she will vomit. This data would be what type of data? a. objective b. reflective c. subjective d. introspective - CORRECT ANSWER C" "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. focused assessment - CORRECT ANSWER B" "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 - CORRECT ANSWER C" "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 - CORRECT ANSWER C" "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 perception 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. - CORRECT ANSWER D" "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 one month ago d. 2- x 5 cm scar present on the right forearm. - CORRECT ANSWER D" "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. including the patient and family members d. establishing a timeline for planned outcomes - CORRECT ANSWER C" "How does the nurse assess for tactile fremitus in a patient? A. By placing the fingertips on the sides of the neck B. By placing the thumb on the spinous process of the patienT C. By placing warmed hands sideways on the posterolateral chest wall D. By placing the palmar base of one hand to touch the patient's chest - CORRECT ANSWER d" "The student nurse is listing the characteristics of normal breath sounds. Which characteristics of normal breath sounds should the student nurse include? Select all that apply. A. Amplitude B. Depth C. Pitch D. Quality E. Pressure - CORRECT ANSWER A C D" "The nurse starts to count the ribs of the patient from the angle of Louis. Which statement precisely describes the "angle of Louis"? A. It is continuous with the first rib. B. It marks the top edge of the sternum .C. It is also known as the suprasternal notch .D. It is the articulation of the manubrium and the body of the sternum. - CORRECT ANSWER D" "The nurse notices that a patient occasionally sighs when breathing. What should the nurse expect to happen as a result of sighing? A. It expands the alveoli. B. It leads to tachypnea. C. It causes hypoventilation. D. It leads to slow breathing. - CORRECT ANSWER A" "While assessing the tactile fremitus of the patient, the nurse learns that the fremitus is decreased. Which disorder may be diagnosed in the patient? A. Bronchitis B. Pleural effusion C. Lobar pneumonia D. Pulmonary infarction - CORRECT ANSWER B" "The nurse is assessing the bronchial breath sounds of a patient. Where should the nurse place the stethoscope? A. Over the trachea and the larynx B. Over the peripheral lung fields C. Posterior between the scapulae D. Anterior near the upper sternum - CORRECT ANSWER A" "During the chest assessment of a patient, which reference line does the nurse note on the posterior chest wall? A. The midspinal line B. The midaxillary line C. The midsternal line D. The midclavicular line - CORRECT ANSWER A" "What action should the nurse include when auscultating the anterior chest of a patient for breath sounds? Select all that apply .A. Starts the auscultation at the apices in the supraclavicular areaS B. Auscultates and listens for one full respiration in each location C. Examines one side completely and then examines the other side D. Listens with a stethoscope over the breast in the female patient E. Completes the examination by auscultating down to the sixth rib - CORRECT ANSWER A B E" "The nurse is caring for a patient with a regular breathing rate of eight breaths per minute. What is the most likely cause for this condition? A. Prolonged bed rest B. Splinting of the chest C. Overdose of stimulants D. Drug-induced depression - CORRECT ANSWER D" "The function of the trachea and bronchi is to: A. transport gases between the environment and the lung parenchyma. B. condense inspired air for better gas exchange. C. moisturize air for optimum respiration. D. increase air turbulence and velocity for maximum gas transport. - CORRECT ANSWER A" "Stridor is a high-pitched, inspiratory crowing sound commonly associated with: A. upper airway obstruction. B. atelectasis. C. congestive heart failure .D. pneumothorax. - CORRECT ANSWER A" "Percussion of the chest is: A. a useful technique for identifying small lesions in lung tissue. B. helpful only in identifying surface alterations of lung tissue. C. is not influenced by the overlying chest muscle and fat tissue. D. normal if a dull note is elicited. - CORRECT ANSWER B" "Which of the following pairs correctly expresses the relationship to the lobes of the lungs and their anatomic position ?A. Upper lobes—lateral chest B. Upper lobes—posterior chest C. Lower lobes—posterior chest D. Lower lobes—anterior chest - CORRECT ANSWER C" "An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n): A. compensatory increase in respiratory parenchyma .B. increase in estrogen. C. increase in surfactant .D. increase in tidal volume. - CORRECT ANSWER B" "A flat macular hemorrhage is called a(n) :A. purpura. B. ecchymosis. C. petechiae. D. hemangioma. - CORRECT ANSWER A" "A scooped-out, shallow depression in the skin is called a(n): A. ulcer. B. excoriation. C. fissure. D. erosion. - CORRECT ANSWER D" "Risk factors that may lead to skin disease and breakdown include: A. loss of protective cushioning of the dermal skin layer. B. decreased vascular fragility. C. a lifetime of environmental trauma. D. increased thickness of the skin. - CORRECT ANSWER C" "The components of a nail examination include: A. Contour, consistency, and color B. Shape, surface, circulation C. Clubbing, pitting, and grooving D. Texture, toughness, and translucency - CORRECT ANSWER A" "What term refers to a linear skin lesion that runs along a nerve route? A. Zosteriform B. Annular C. Dermatome D. Shingles - CORRECT ANSWER A" "To determine if a dark-skinned patient is pale, the nurse should assess the color of the: A. conjunctivae. B. earlobes. C. palms of the hands. D. skin in the antecubital space. - CORRECT ANSWER A" "An example of a primary lesion is a(n): A. erosion. B. ulcer .C. urticaria. D. port-wine stain. - CORRECT ANSWER C" "When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? A. Excessive bruising B. Hyperpigmentation C. Melasma D. Drug reactions - CORRECT ANSWER D" "A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic? A. There are two types of sweat glands: eccrine glands and sebaceous glands. B. The evaporation of sweat, a dilute saline solution, increases body temperature. C. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel .D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature. - CORRECT ANSWER D" "Functions of the skin include: A. production of vitamin C .B. temperature regulation. C. production of new cells by melanocytes. D. secretion of a drying substance called sebum. - CORRECT ANSWER B" "Select the best description of the secretion of the eccrine glands. A) Thick, milky B) Dilute saline solution C) Protective lipid substance D) Keratin - CORRECT ANSWER B" "To assess for early jaundice, you will assess: A. sclera and hard palate B. nail beds C. lips D. all visible skin surfaces - CORRECT ANSWER A" "Checking for skin temperature is best accomplished by using :A. the palmar surface of the hands B. the ventral surface of the hands C. the fingertips D. the dorsal surface of the hands - CORRECT ANSWER D" "Assessing a patient's skin turgor is done to assess which clinical finding? A. Edema B. Dehydration C. Vitiligo D. Scleroderma - CORRECT ANSWER B" "The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect? A. Cyanosis B. Flushing C. Rubor D. Jaundice - CORRECT ANSWER D" "The nurse recognizes which of these persons is at greatest risk for undernutrition? a.5-month-old infant b.50-year-old woman c.20-year-old college student d..30-year-old hospital administrator - CORRECT ANSWER A" "When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that: a.Are in excess of daily body requirements. b.Provide for the minimum body needs. c.Provide for daily body requirements but do not support increased metabolic demands. d.Provide for daily body requirements and support increased metabolic demands. - CORRECT ANSWER D" "The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find? a.Obesity b.Hypotension c.Osteomalacia (softening of the bones d.Coronary artery disease - CORRECT ANSWER C" "For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity? a.Calorie count of nutrients b.Anthropometric measures c.Complete physical examination d.Measurement of weight and weight history - CORRECT ANSWER D" "A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information? a.Food diary b.Calorie count c.24-hour recall d.Food-frequency questionnaire - CORRECT ANSWER D" "The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? a.Absorption of nutrients may be impaired .b.Constipation may represent a food allergy .c.The patient may need emergency surgery to correct the problem. d.Gastrointestinal problems will increase her caloric demand. - CORRECT ANSWER A" "During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? a.Certain drugs can affect the metabolism of nutrients. b.The nurse needs to assess the patient for allergic reactions. c.Medications need to be documented in the record for the physician's review. d.Medications can affect one's memory and ability to identify - CORRECT ANSWER A" "A patient tells the nurse that his food simply does not have any taste anymore. The nurse's best response would be: a."That must be really frustrating." b."When did you first notice this change? "c."My food doesn't always have a lot of taste either." d."Sometimes that happens, but your taste will come back." - CORRECT ANSWER B" "The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult? a.Increase in taste and smell b.Living alone on a fixed income c.Change in cardiovascular status d.Increase in gastrointestinal motility and absorption - CORRECT ANSWER B" "When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a.Height and weight .b.Leg circumference. c.Skinfold thickness of the biceps. d.Hip a