N125 Exam 1 Study Guide Questions With Complete
Solutions
A 4-year-old boy is brought to the emergency department by his
mother. She says he points to his stomach and says, It hurts so
bad. Which pain assessment tool would be the best choice when
assessing this childs pain? Correct Answer FACES
A man is at the clinic for a physical examination. He states that
he is very anxious about the physical examination. What steps
can the nurse take to make him more comfortable?
a.Appear unhurried and confident when examining him.
b.Stay in the room when he undresses in case he needs
assistance.
c.Ask him to change into an examining gown and to take off his
undergarments.
d.Defer measuring vital signs until the end of the examination,
which allows him time to become comfortable. Correct Answer
A
A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that
apply.)
a. The review of patient data in the medical record
b. Confirming a patient's self-report of abdominal pain by
inspecting the abdomen
c. Reporting results of an ongoing assessment to a nurse
working the next scheduled shift
,d. Analyzing a set of signs revealing lower leg weakness and
unsteady gait with a pattern of mobility alteration
e. Conducting an interview of a family caregiver Correct
Answer A, B, D
A nurse enters a patient's room at the beginning of a shift to
conduct an assessment of his condition following a blood
transfusion. The nurse cared for the patient on the previous day
as well. The patient has a number of issues he wishes to share
with the nurse, who takes time to explore each issue. The nurse
also assesses the patient and finds no signs or symptoms of a
reaction to the blood product. The nurse observed the patient the
prior day and sees a change in his behavior, a reluctance to get
out of bed and ambulate. Which of the following actions
improve the nurse's ability to make clinical decisions about this
patient? (Select all that apply.)
1. Working the same shift each day
2. Spending time during the patient assessment
3. Knowing the early mobility protocol guidelines
4. Caring for the patient on consecutive days.
5. Knowing the pattern of patient behavior about ambulation
Correct Answer 2, 4, 5
A nurse is assigned to a new patient admitted to the nursing unit
following admission through the emergency department. The
nurse collects a nursing history and interviews the patient. Place
the following steps for making a nursing diagnosis in the correct
order, beginning with the first step:
, 1. Considers context of patient's health problem and selects a
related factor
2. Reviews assessment data, noting objective and subjective
clinical information
3. Clusters clinical cues that form a pattern
4. Identify appropriate assessment findings for diagnosis.
5. Identify a nursing diagnosis. Correct Answer 2, 3, 5, 1, 4
Assessment
Diagnosis
Planning
Intervention
Implementation
A nurse is assigned to care for a woman who is expecting her
first child. The nurse organizes herself and plans to gather data
about the patient by applying Pender's health promotion model,
including the patient's characteristics and experiences and
situational influences. She plans to observe patient behavior and
consider the patient's psychosocial issues. Such data will offer a
clear understanding to help the nurse identify the patient's needs.
This is an example of which of the following concepts? (Select
all that apply.)
1. Diagnostic reasoning
2. Deductive reasoning
3. Inductive reasoning
4. Assessment
5. Problem solving Correct Answer 2, 4
Solutions
A 4-year-old boy is brought to the emergency department by his
mother. She says he points to his stomach and says, It hurts so
bad. Which pain assessment tool would be the best choice when
assessing this childs pain? Correct Answer FACES
A man is at the clinic for a physical examination. He states that
he is very anxious about the physical examination. What steps
can the nurse take to make him more comfortable?
a.Appear unhurried and confident when examining him.
b.Stay in the room when he undresses in case he needs
assistance.
c.Ask him to change into an examining gown and to take off his
undergarments.
d.Defer measuring vital signs until the end of the examination,
which allows him time to become comfortable. Correct Answer
A
A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that
apply.)
a. The review of patient data in the medical record
b. Confirming a patient's self-report of abdominal pain by
inspecting the abdomen
c. Reporting results of an ongoing assessment to a nurse
working the next scheduled shift
,d. Analyzing a set of signs revealing lower leg weakness and
unsteady gait with a pattern of mobility alteration
e. Conducting an interview of a family caregiver Correct
Answer A, B, D
A nurse enters a patient's room at the beginning of a shift to
conduct an assessment of his condition following a blood
transfusion. The nurse cared for the patient on the previous day
as well. The patient has a number of issues he wishes to share
with the nurse, who takes time to explore each issue. The nurse
also assesses the patient and finds no signs or symptoms of a
reaction to the blood product. The nurse observed the patient the
prior day and sees a change in his behavior, a reluctance to get
out of bed and ambulate. Which of the following actions
improve the nurse's ability to make clinical decisions about this
patient? (Select all that apply.)
1. Working the same shift each day
2. Spending time during the patient assessment
3. Knowing the early mobility protocol guidelines
4. Caring for the patient on consecutive days.
5. Knowing the pattern of patient behavior about ambulation
Correct Answer 2, 4, 5
A nurse is assigned to a new patient admitted to the nursing unit
following admission through the emergency department. The
nurse collects a nursing history and interviews the patient. Place
the following steps for making a nursing diagnosis in the correct
order, beginning with the first step:
, 1. Considers context of patient's health problem and selects a
related factor
2. Reviews assessment data, noting objective and subjective
clinical information
3. Clusters clinical cues that form a pattern
4. Identify appropriate assessment findings for diagnosis.
5. Identify a nursing diagnosis. Correct Answer 2, 3, 5, 1, 4
Assessment
Diagnosis
Planning
Intervention
Implementation
A nurse is assigned to care for a woman who is expecting her
first child. The nurse organizes herself and plans to gather data
about the patient by applying Pender's health promotion model,
including the patient's characteristics and experiences and
situational influences. She plans to observe patient behavior and
consider the patient's psychosocial issues. Such data will offer a
clear understanding to help the nurse identify the patient's needs.
This is an example of which of the following concepts? (Select
all that apply.)
1. Diagnostic reasoning
2. Deductive reasoning
3. Inductive reasoning
4. Assessment
5. Problem solving Correct Answer 2, 4
