63. During an assessment of an infant, the nurse notes that the fontanels are depressed
and sunken. The nurse suspects which condition?
A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure
B) Dehydration
Pages: 265-266. Depressed and sunken fontanels occur with dehydration or
malnutrition. Mental retardation and rickets have no effect on fontanels.
Increased intracranial pressure would cause tense or bulging, and possibly
pulsating fontanels.
,12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient
Chinese philosophy of Tao. The nurse recognizes which statement that most accurately
reflects "health" in an Asian with this belief?
A) A person is able to work and produce.
B) A person is happy, stable, and feels good.
C) All aspects of the person are in perfect balance.
D) A person is able to care for others and function socially.
C) All aspects of the person are in perfect balance.
Page: 21 Many Asians believe in the yin/yang theory, in which health is
believed to exist when all aspects of the person are in perfect balance. The
other statements do not describe this theory.
30. 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?"
A) "How do you feel today?"
Page: 74. Judge mood and affect by body language and facial expression and
by asking directly, "How do you feel today?" or "How do you usually feel?" The
, mood should be appropriate to the person's place and condition and should
change appropriately with topics.
46. 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 on the record for the physician's review.
D) Medications can affect one's memory and ability to identify food eaten in the last 24
hours.
A) Certain drugs can affect the metabolism of nutrients.
Page: 183
Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives,
antineoplastic drugs, steroids, and oral contraceptives are drugs that can
interact with nutrients, impairing their digestion, absorption, metabolism, or
use. The other responses are not correct.
39. When performing a physical examination, safety must be considered to protect the
examiner and the patient against the spread of infection. Which of these statements
describes the most appropriate action the nurse should take when performing a physical
examination?
A) There is no need to wash one's hands after removing gloves, as long as the gloves are
still intact.
B) Wash hands before and after every physical patient encounter.
C) Wash hands between the examination of each body system to prevent the spread of
bacteria from one part of the body to another.
, D) Wear gloves throughout the entire examination to demonstrate to the patient concern
regarding the spread of infectious diseases.
B) Wash hands before and after every physical patient encounter.
Page: 120. The nurse should wash his or her hands before and after every
physical patient encounter; after contact with blood, body fluids, secretions,
and excretions; after contact with any equipment contaminated with body
fluids; and after removing gloves. Hands should be washed after gloves have
been removed, even if the gloves appear to be intact. Gloves should be worn
when there is potential contact with any body fluids.
21. In recording the childhood illnesses of a patient who denies having had any, which
note by the nurse would be most accurate?
A. Patient denies usual childhood illnesses.
B. Patient states he was a "very healthy" child.
C. Patient states sister had measles, but he didn't.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep
throat.
Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox,
pertussis, and strep throat. Avoid recording "usual childhood illnesses"
because an illness common in the person's childhood may be unusual today
(e.g., measles).
and sunken. The nurse suspects which condition?
A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure
B) Dehydration
Pages: 265-266. Depressed and sunken fontanels occur with dehydration or
malnutrition. Mental retardation and rickets have no effect on fontanels.
Increased intracranial pressure would cause tense or bulging, and possibly
pulsating fontanels.
,12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient
Chinese philosophy of Tao. The nurse recognizes which statement that most accurately
reflects "health" in an Asian with this belief?
A) A person is able to work and produce.
B) A person is happy, stable, and feels good.
C) All aspects of the person are in perfect balance.
D) A person is able to care for others and function socially.
C) All aspects of the person are in perfect balance.
Page: 21 Many Asians believe in the yin/yang theory, in which health is
believed to exist when all aspects of the person are in perfect balance. The
other statements do not describe this theory.
30. 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?"
A) "How do you feel today?"
Page: 74. Judge mood and affect by body language and facial expression and
by asking directly, "How do you feel today?" or "How do you usually feel?" The
, mood should be appropriate to the person's place and condition and should
change appropriately with topics.
46. 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 on the record for the physician's review.
D) Medications can affect one's memory and ability to identify food eaten in the last 24
hours.
A) Certain drugs can affect the metabolism of nutrients.
Page: 183
Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives,
antineoplastic drugs, steroids, and oral contraceptives are drugs that can
interact with nutrients, impairing their digestion, absorption, metabolism, or
use. The other responses are not correct.
39. When performing a physical examination, safety must be considered to protect the
examiner and the patient against the spread of infection. Which of these statements
describes the most appropriate action the nurse should take when performing a physical
examination?
A) There is no need to wash one's hands after removing gloves, as long as the gloves are
still intact.
B) Wash hands before and after every physical patient encounter.
C) Wash hands between the examination of each body system to prevent the spread of
bacteria from one part of the body to another.
, D) Wear gloves throughout the entire examination to demonstrate to the patient concern
regarding the spread of infectious diseases.
B) Wash hands before and after every physical patient encounter.
Page: 120. The nurse should wash his or her hands before and after every
physical patient encounter; after contact with blood, body fluids, secretions,
and excretions; after contact with any equipment contaminated with body
fluids; and after removing gloves. Hands should be washed after gloves have
been removed, even if the gloves appear to be intact. Gloves should be worn
when there is potential contact with any body fluids.
21. In recording the childhood illnesses of a patient who denies having had any, which
note by the nurse would be most accurate?
A. Patient denies usual childhood illnesses.
B. Patient states he was a "very healthy" child.
C. Patient states sister had measles, but he didn't.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep
throat.
Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox,
pertussis, and strep throat. Avoid recording "usual childhood illnesses"
because an illness common in the person's childhood may be unusual today
(e.g., measles).
