EXAM QUESTIONS AND ANSWERS
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Health Promotion and Disease Prevention
1. Questions
1. 1.ID: 9477077870
A Mexican-American client with epilepsy is being seen at the clinic for an initial
examination. What is the primary purpose of including cultural information in
the health assessment?
A. Confirm the medical diagnosis
B. Make accurate nursing diagnoses
C. Identify any hereditary traits related to the epilepsy
D. Determine what the client believes has caused the
epilepsy Correct
Rationale: The primary purpose for including cultural information in the health
assessment is to determine what the client believes has caused the illness. In
Integrated Process:culture,
Mexican-American Nursingepilepsy
Process/Assessment
is seen as a reflection of physical
Content Area: Cultural Awareness
imbalance. Although the nurse may obtain data related to family history
Priority Concepts:
(hereditary) Culture, nursing
and formulate Evidencediagnoses, these are not the primary
HESI Concepts: Cultural/Spiritual, Evidence-Based
reasons for including cultural information in the health Practice/Evidence
assessment. A nurse
Awardedassessment
gathers 1.0 points out
dataof but
1.0 does
possible
not points.
confirm a medical diagnosis.
Test-Taking Strategy: Eliminate the option that indicates to confirm a medical
diagnosis, because this is not the role of the nurse. To select from the
remaining options, recall that cultural beliefs exist in relation to the cause of a
disease; this will direct you to the correct option. Review: the nurse’s role in
data collection and cultural considerations .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th
ed., p. 52). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
2. 2.ID: 9477073956
A nurse is reviewing the findings of a physical examination that have been
documented in a client's record. Which piece of information does the nurse
recognize as objective data?
A. The client is allergic to strawberries.
B. The last menstrual period was 30 days ago.
C. The client takes acetaminophen (Tylenol) for headaches.
D. A 1 × 2-inch (5 cm) scar is present on the lower right portion ofthe
, abdomen.
Correct
nurse observes, and laboratory study and diagnostic test results. Allergies, the
date of the client’s last menstrual period, and the reported use of medication for
headaches are all subjective data.
Test-Taking Strategy: Eliminate the options that are comparable or alike and
include data that the nurse would obtain from the client during the health
history. Review: the difference between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th
ed., pp. 2, 55). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
Rationale: Subjective data, collected during the health history, consist of
information that the client gives about himself or herself. Objective data are
obtained through physical examination and vital signs measurements, what the
, Awarded 1.0 points out of 1.0 possible points.
2. 3.ID: 9477071188
A nurse performing a cranial nerve assessment is testing the function of the
oculomotor, trochlear, and abducens nerves. Which of the following parameters
does the nurse check to determine the function of these nerves?
A. Tongue symmetry
B. Eye movements Correct
C. Facial symmetry
D. Corneal reflex
Rationale: Testing of the oculomotor, trochlear, and abducens nerves, which
are usually assessed together, involves checking the pupils for size, regularity,
equality, direct and consensual light reaction, and accommodation, as well as
testing of extraocular movements through the cardinal positions of gaze.
Inspection of the tongue for symmetry reveals the function of cranial nerve XII
(hypoglossal nerve). Assessment of facial symmetry reveals the function of
cranial nerve VII (facial nerve). The corneal reflex reflects the function of the
sensory afferent in cranial nerve V (trigeminal nerve) and the motor efferent in
cranial nerve VII (facial nerve).
Test-Taking Strategy: Knowledge regarding the function of the various cranial
nerves is needed to answer this question. Recalling that the oculomotor,
trochlear, and abducens nerves are related to pupil function and eye
movements will direct you to the correct option. Review: the functions of these
nerves .
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1778). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477071128
A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks
ago for symptoms of a cold and is now complaining of chest congestion and
cough. The nurse should proceed with the examination by collecting which?
A. Data related to follow-up care
B. A complete (total health) database Incorrect
C. Data related to the respiratory system Correct
D. Data related to the treatment for the cold
, Rationale: An episodic database is compiled for a limited or short-term problem
and is focused mainly on one problem or body system. The history and
examination will be focused primarily on the respiratory system in this client. A
complete database includes a complete health history and a full physical
examination. It describes the client’s current and past state of health and forms
a baseline against which all future changes can be measured. A follow-up
database is used to evaluate an identified problem at regular and appropriate
intervals.
Test-Taking Strategy: Focusing on the data in the question and noting the
words “now complaining of chest congestion and cough” will direct you to the
correct option. Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th
ed., p. 8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Gas Exchange
HESI Concepts: Evidence-Based Practice/Evidence, Oxygenation/Gas
Exchange
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 9477071111
A fclient fis fbrought fto fthe femergency fdepartment fafter fa fmotor fvehicle
faccident.fThe fclient fis falert fand fcooperative fbut fhas fsustained fmultiple
ffractures fof fthe flegs. fHow fshould fthe fnurse fproceed fwith fdata fcollection?
A. Collect fhealth fhistory finformation ffirst, fthen fperform
fthefphysical fexamination