NR 235 final exam || all accurately answered.
Health assessment is a foundational and priority nursing skill. This essential skill requires
registered nurses to: correct answers identify normal and abnormal findings
A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age
48. The doctor recommended that this patient have a colonoscopy this year. This is an example
of: correct answers secondary health prevention
The four techniques of health assessment include inspection, palpation, percussion, and
_________________. correct answers auscultation
The nurse is preparing to conduct a complete health history on a new patient who has just arrived
at the walk-in clinic. The nurse is going to use the CLEAR mnemonic to collect information.
What does CLEAR stand for? Select all that apply. correct answers Center
Listen
Empathy
attention
respect
A home health nurse is assessing a 94-year-old patient with a severe cognitive impairment. The
daughter with whom the patient lives states that her mom only eats less than half of all her meals.
What will you document? correct answers Some patients may be unreliable because of decreased
cognitive ability or mentation. Secondary sources will be needed to provide information for the
health history. If this occurs, document: "Patient is unreliable. Report by patient's daughter."
You are about to start the health history. The patient is present with his daughter. Which of the
following priority steps should you take before you start the health history? correct answers This
is correct. If family members are present during the interview, the nurse should clarify who is
present rather than assume it is the wife, daughter, parent, or significant other. It is the nurse's
responsibility to obtain permission from the patient for the family members to be present and
participate in the interview process.
The four fundamental topics of a psychosocial assessment are: correct answers Fundamental
topics included in the psychosocial assessment include behavioral, environmental, social, and
financial/economic.
The nurse is performing a mental health assessment on a 42-year-old male patient. As part of the
mental health assessment, the nurse needs to assess the patient's orientation to
____________________, ____________________, and ____________________. correct
answers person, place, time
____________________ data are pieces of information specifically reported by the patient in a
health history. correct answers subjective data
, The purpose of measuring body mass index (BMI) is: correct answers BMI is a screening tool
identifying the amount of body fat based on height and weight that applies to adult men and
women.
A nursing instructor is discussing individuals who are at risk for malnutrition with a nursing
student. The instructor recognizes that the student needs further education if he indicates which
of the following groups of individuals as being at risk for malnutrition? correct answers College
students are not a population that is considered at risk for malnutrition but, rather, overnutrition.
While the patient is eating her meal you observe her having difficulty swallowing solid food. The
medical term for difficulty swallowing is: correct answers dysphagia
A patient is having diagnostic laboratory tests drawn to assess her nutritional status. The nurse
explains to the patient that there are several laboratory tests that will be used as assessment tools
for nutritional status, including which of the following? Select all that apply. correct answers
Triglyceride levels are used to assess the amount of fat in the blood.
Ferritin levels are used to assess the amount of iron in the blood to identify iron deficiency
anemia.
Prealbumin levels are used to assess protein deficiency.
Health assessment requires the collection of data to accurately and safely care for every patient.
What is the correct sequence of assessment techniques that will provide objective assessment
data (1-4)? correct answers 1. inspection
2, palpation
3. percussion
4. auscultation
The patient is complaining of shortness of breath and mild chest pain. You are about to start the
focused assessment. What should be the nurse's first action? correct answers wash hands in front
of patient
Which of the following is the correct sequence in which to perform a physical assessment?
correct answers General survey, temperature, pulse, respiratory rate, blood pressure
Mary Jane is getting a physical examination prior to starting her new job. You take her vital
signs: temperature (97.8°F), radial pulse 92 reg, + 2 amplitude, respiratory rate (20), and blood
pressure 150/96. What is the category of Mary's blood pressure? correct answers stage 1
hypertension
You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the
apical pulse at 104 and irregular. What is the pulse deficit? ___________ correct answers 12
(apical - radial)
Normal respirations are ________ to _________ breaths per minute. correct answers 12 to 20
Health assessment is a foundational and priority nursing skill. This essential skill requires
registered nurses to: correct answers identify normal and abnormal findings
A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age
48. The doctor recommended that this patient have a colonoscopy this year. This is an example
of: correct answers secondary health prevention
The four techniques of health assessment include inspection, palpation, percussion, and
_________________. correct answers auscultation
The nurse is preparing to conduct a complete health history on a new patient who has just arrived
at the walk-in clinic. The nurse is going to use the CLEAR mnemonic to collect information.
What does CLEAR stand for? Select all that apply. correct answers Center
Listen
Empathy
attention
respect
A home health nurse is assessing a 94-year-old patient with a severe cognitive impairment. The
daughter with whom the patient lives states that her mom only eats less than half of all her meals.
What will you document? correct answers Some patients may be unreliable because of decreased
cognitive ability or mentation. Secondary sources will be needed to provide information for the
health history. If this occurs, document: "Patient is unreliable. Report by patient's daughter."
You are about to start the health history. The patient is present with his daughter. Which of the
following priority steps should you take before you start the health history? correct answers This
is correct. If family members are present during the interview, the nurse should clarify who is
present rather than assume it is the wife, daughter, parent, or significant other. It is the nurse's
responsibility to obtain permission from the patient for the family members to be present and
participate in the interview process.
The four fundamental topics of a psychosocial assessment are: correct answers Fundamental
topics included in the psychosocial assessment include behavioral, environmental, social, and
financial/economic.
The nurse is performing a mental health assessment on a 42-year-old male patient. As part of the
mental health assessment, the nurse needs to assess the patient's orientation to
____________________, ____________________, and ____________________. correct
answers person, place, time
____________________ data are pieces of information specifically reported by the patient in a
health history. correct answers subjective data
, The purpose of measuring body mass index (BMI) is: correct answers BMI is a screening tool
identifying the amount of body fat based on height and weight that applies to adult men and
women.
A nursing instructor is discussing individuals who are at risk for malnutrition with a nursing
student. The instructor recognizes that the student needs further education if he indicates which
of the following groups of individuals as being at risk for malnutrition? correct answers College
students are not a population that is considered at risk for malnutrition but, rather, overnutrition.
While the patient is eating her meal you observe her having difficulty swallowing solid food. The
medical term for difficulty swallowing is: correct answers dysphagia
A patient is having diagnostic laboratory tests drawn to assess her nutritional status. The nurse
explains to the patient that there are several laboratory tests that will be used as assessment tools
for nutritional status, including which of the following? Select all that apply. correct answers
Triglyceride levels are used to assess the amount of fat in the blood.
Ferritin levels are used to assess the amount of iron in the blood to identify iron deficiency
anemia.
Prealbumin levels are used to assess protein deficiency.
Health assessment requires the collection of data to accurately and safely care for every patient.
What is the correct sequence of assessment techniques that will provide objective assessment
data (1-4)? correct answers 1. inspection
2, palpation
3. percussion
4. auscultation
The patient is complaining of shortness of breath and mild chest pain. You are about to start the
focused assessment. What should be the nurse's first action? correct answers wash hands in front
of patient
Which of the following is the correct sequence in which to perform a physical assessment?
correct answers General survey, temperature, pulse, respiratory rate, blood pressure
Mary Jane is getting a physical examination prior to starting her new job. You take her vital
signs: temperature (97.8°F), radial pulse 92 reg, + 2 amplitude, respiratory rate (20), and blood
pressure 150/96. What is the category of Mary's blood pressure? correct answers stage 1
hypertension
You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the
apical pulse at 104 and irregular. What is the pulse deficit? ___________ correct answers 12
(apical - radial)
Normal respirations are ________ to _________ breaths per minute. correct answers 12 to 20
