Nursing Assessment Exam 1
____ is the main source of fatty acids and is essential for normal growth and
development. - ANS - Fat.
\_____ artery is most frequently used to measure heart rate because it is accessible
and easily palpated. - ANS - Radial
\_____ is used to gather more information. - ANS - Clarification.
\_____ reflection is repeating what the patient said and encourages elaboration or more
information. - ANS - Reflection
\______ is used when inconsistencies are noted between a patient report and a nurse's
observations. - ANS - Confrontation
\_______ condenses and orders data to clarify the sequence of events for that pt. It
emphasizes data related to health promotion, disease protection, and resolving health
problems - ANS - Summary
\_______ is repeating what the patient says in different words to confirm interpretation. -
ANS - Restatement
\_______ is used to share conclusions drawn from data. Pt. may then confirm, deny, or
revise - ANS - Interpretations
\_______ uses verbal and nonverbal phrases to encourage patients to continue to talk
further. - ANS - Facilitation
\A mother of three is being seen for a screening assessment. While planning the initial
part of the visit with this patient, the nurse needs to ensure that:
a)The patient receives a refill for her thyroid medication.
b)The patient is instructed on preventive measures for hypertension.
C)Other family members are present during the interview.
D)Information about the patient's lifestyle habits is gathered. - ANS - Correct Answer: D
Rationale: There are multiple types of health assessments. If a patient receives a refill,
this is an episodic or follow-up assessment. If a patient is instructed in preventive
measures, this is more along the lines of a comprehensive assessment. A screening
assessment would require the nurse to have data about lifestyle habits.
\A nurse is assessing a female teenager. The nurse asks the young woman to bend
over and touch her toes. The nurse assesses the curvature of the spine as a means of
detecting scoliosis. Assessing the curvature of the spine is an example of:
A)Health education
B)Primary prevention
C)Secondary prevention
,D)Tertiary prevention - ANS - Correct Answer: C
Rationale: Primary prevention is preventing the disease before it begins. Secondary
prevention means that the nurse is trying to detect disease as early as possible to
improve outcomes.
\A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need
to assess her blood pressure. The nurse explains to the patient that:
A) Using a cuff that is too narrow will give a reading that is inaccurate and high.
B) Deflating the cuff too quickly will make the reading inaccurate and high.
C) Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high.
D) Waiting 3 minutes before repeating the blood pressure measurement will result in a
false-high blood pressure measurement. - ANS - Correct Answer: A
Rationale: Cuff width should be 40% of the circumference of the limb to be used to
assess blood pressure. Quick deflation (faster than 2 mm Hg to 3 mm Hg per second)
makes the blood pressure measurement inaccurate and low. Waiting 3 minutes between
repeat blood pressure measurements will help ensure an accurate second reading.
\After completing a dressing change and tidying up the room, the nurse asks the patient
if she needs anything. The patient responds, "I am just tired of being tired. Ever since
my husband died, I can't seem to sleep more than 3 to 4 hours a night. I can't find
anything fun to do, and all my friends seem to have disappeared." The nurse discloses
this information to the social worker and recommends that the patient:
A) Start taking diphenhydramine at bedtime.
B) Be assessed on the Beck short form.
C) Undergo AUDIT assessment.
D) Undergo CAGE assessment. - ANS - Correct Answer: B
Rationale: The Beck short form is used to screen for depression. The nurse could talk
with a nurse practitioner or physician about a sleep aid, but further assessment is
needed. The AUDIT and CAGE tests are used to assess for alcohol use.
\Assessment of circulation, motion, and sensation is done every 8 hours in a patient
recovering from a laminectomy 3 days after surgery. The patient had the surgery for
consistent low back pain. Now on day 3, the patient has a burning sensation on the
lateral edge of the right foot. This is best described as:
A) Cellulitis.
B) Nociceptive pain.
C) Fasciitis.
D) Neuropathic pain. - ANS - Correct Answer: D
Rationale: Cellulitis is an interstitial infection. Nociceptive pain is usually associated with
tissue destruction or damage. Neuropathy is connected to nerve-related pain. It would
, appear that a nerve is being disturbed as a result of the surgery or the initial disease
process. Burning sensation is a classic presentation or complaint related to nerve pain.
\Because a nurse seeks to create a patient-centered interview process, the nurse will:
A) Ask the patient, "Do you suffer from any arthralgias?"
B) Give the patient as little information as possible to avoid fear.
C)Ask the patient, "Can you please tell me more about your spells?"
D) Inform the patient, "You don't have to share anything with me that makes you
uncomfortable." - ANS - Correct Answer: C
Rationale: The word "arthralgia" may be a word that many patients do not understand.
The nurse needs to be careful when withholding information related to not wanting to
"scare" the patient. It is best if the nurse works with the patient on identifying what
information the patient wants to receive. There could be an age-appropriate component
to this (i.e., children), in which case the nurse will work with caregivers to ensure that all
required information is given. In option "C," the patient has used the word "spells." The
nurse should not discourage this but should investigate further. In option "D," the nurse
should not say this; often there is sensitive material that must be covered or addressed
to provide adequate care.
\Begin interviews with what type of questions? - ANS - open-ended. encourage a
free-flowing open response.
\Body temperature is regulated by the ______. Expected temperature ranges from 96.4
to 99.1. - ANS - Hypothalamus
\Causes of hyperlipidemia? - ANS - dietary fat and genetics.
\Clinical findings of hyperlipidemia? - ANS - Hyperlipidemia is not associated with
clinical symptoms until cardiovascular event occurs.
Biochemical indications = Elevations in serum lipids.
In adults, cholesterol levels from 200 to 239 mg/dL considered borderline high.
Cholesterol levels of 240 mg/dL or higher are considered high.
\Collection of objective data from a patient with a swollen left elbow includes which
piece of equipment?
A)Magnifier
B)Blood pressure cuff
C)Snellen chart
D)Goniometer - ANS - Correct Answer: D
Rationale: The goniometer is used to measure extension or flexion of joints. The
magnifier is not used (unless there is a lesion that needs to be assessed). The blood
pressure cuff may be indicated if that is a regular part of intake. The Snellen chart is
used for visual acuity.
____ is the main source of fatty acids and is essential for normal growth and
development. - ANS - Fat.
\_____ artery is most frequently used to measure heart rate because it is accessible
and easily palpated. - ANS - Radial
\_____ is used to gather more information. - ANS - Clarification.
\_____ reflection is repeating what the patient said and encourages elaboration or more
information. - ANS - Reflection
\______ is used when inconsistencies are noted between a patient report and a nurse's
observations. - ANS - Confrontation
\_______ condenses and orders data to clarify the sequence of events for that pt. It
emphasizes data related to health promotion, disease protection, and resolving health
problems - ANS - Summary
\_______ is repeating what the patient says in different words to confirm interpretation. -
ANS - Restatement
\_______ is used to share conclusions drawn from data. Pt. may then confirm, deny, or
revise - ANS - Interpretations
\_______ uses verbal and nonverbal phrases to encourage patients to continue to talk
further. - ANS - Facilitation
\A mother of three is being seen for a screening assessment. While planning the initial
part of the visit with this patient, the nurse needs to ensure that:
a)The patient receives a refill for her thyroid medication.
b)The patient is instructed on preventive measures for hypertension.
C)Other family members are present during the interview.
D)Information about the patient's lifestyle habits is gathered. - ANS - Correct Answer: D
Rationale: There are multiple types of health assessments. If a patient receives a refill,
this is an episodic or follow-up assessment. If a patient is instructed in preventive
measures, this is more along the lines of a comprehensive assessment. A screening
assessment would require the nurse to have data about lifestyle habits.
\A nurse is assessing a female teenager. The nurse asks the young woman to bend
over and touch her toes. The nurse assesses the curvature of the spine as a means of
detecting scoliosis. Assessing the curvature of the spine is an example of:
A)Health education
B)Primary prevention
C)Secondary prevention
,D)Tertiary prevention - ANS - Correct Answer: C
Rationale: Primary prevention is preventing the disease before it begins. Secondary
prevention means that the nurse is trying to detect disease as early as possible to
improve outcomes.
\A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need
to assess her blood pressure. The nurse explains to the patient that:
A) Using a cuff that is too narrow will give a reading that is inaccurate and high.
B) Deflating the cuff too quickly will make the reading inaccurate and high.
C) Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high.
D) Waiting 3 minutes before repeating the blood pressure measurement will result in a
false-high blood pressure measurement. - ANS - Correct Answer: A
Rationale: Cuff width should be 40% of the circumference of the limb to be used to
assess blood pressure. Quick deflation (faster than 2 mm Hg to 3 mm Hg per second)
makes the blood pressure measurement inaccurate and low. Waiting 3 minutes between
repeat blood pressure measurements will help ensure an accurate second reading.
\After completing a dressing change and tidying up the room, the nurse asks the patient
if she needs anything. The patient responds, "I am just tired of being tired. Ever since
my husband died, I can't seem to sleep more than 3 to 4 hours a night. I can't find
anything fun to do, and all my friends seem to have disappeared." The nurse discloses
this information to the social worker and recommends that the patient:
A) Start taking diphenhydramine at bedtime.
B) Be assessed on the Beck short form.
C) Undergo AUDIT assessment.
D) Undergo CAGE assessment. - ANS - Correct Answer: B
Rationale: The Beck short form is used to screen for depression. The nurse could talk
with a nurse practitioner or physician about a sleep aid, but further assessment is
needed. The AUDIT and CAGE tests are used to assess for alcohol use.
\Assessment of circulation, motion, and sensation is done every 8 hours in a patient
recovering from a laminectomy 3 days after surgery. The patient had the surgery for
consistent low back pain. Now on day 3, the patient has a burning sensation on the
lateral edge of the right foot. This is best described as:
A) Cellulitis.
B) Nociceptive pain.
C) Fasciitis.
D) Neuropathic pain. - ANS - Correct Answer: D
Rationale: Cellulitis is an interstitial infection. Nociceptive pain is usually associated with
tissue destruction or damage. Neuropathy is connected to nerve-related pain. It would
, appear that a nerve is being disturbed as a result of the surgery or the initial disease
process. Burning sensation is a classic presentation or complaint related to nerve pain.
\Because a nurse seeks to create a patient-centered interview process, the nurse will:
A) Ask the patient, "Do you suffer from any arthralgias?"
B) Give the patient as little information as possible to avoid fear.
C)Ask the patient, "Can you please tell me more about your spells?"
D) Inform the patient, "You don't have to share anything with me that makes you
uncomfortable." - ANS - Correct Answer: C
Rationale: The word "arthralgia" may be a word that many patients do not understand.
The nurse needs to be careful when withholding information related to not wanting to
"scare" the patient. It is best if the nurse works with the patient on identifying what
information the patient wants to receive. There could be an age-appropriate component
to this (i.e., children), in which case the nurse will work with caregivers to ensure that all
required information is given. In option "C," the patient has used the word "spells." The
nurse should not discourage this but should investigate further. In option "D," the nurse
should not say this; often there is sensitive material that must be covered or addressed
to provide adequate care.
\Begin interviews with what type of questions? - ANS - open-ended. encourage a
free-flowing open response.
\Body temperature is regulated by the ______. Expected temperature ranges from 96.4
to 99.1. - ANS - Hypothalamus
\Causes of hyperlipidemia? - ANS - dietary fat and genetics.
\Clinical findings of hyperlipidemia? - ANS - Hyperlipidemia is not associated with
clinical symptoms until cardiovascular event occurs.
Biochemical indications = Elevations in serum lipids.
In adults, cholesterol levels from 200 to 239 mg/dL considered borderline high.
Cholesterol levels of 240 mg/dL or higher are considered high.
\Collection of objective data from a patient with a swollen left elbow includes which
piece of equipment?
A)Magnifier
B)Blood pressure cuff
C)Snellen chart
D)Goniometer - ANS - Correct Answer: D
Rationale: The goniometer is used to measure extension or flexion of joints. The
magnifier is not used (unless there is a lesion that needs to be assessed). The blood
pressure cuff may be indicated if that is a regular part of intake. The Snellen chart is
used for visual acuity.
