Exam 1: NSG3160 / NSG 3160 (Latest 2026 / 2027) Health Assessment | 100% Correct Questions & Answers - Galen

Exam 1: NSG3160 / NSG 3160 (Latest 2026 / 2027) Health Assessment | 100% Correct Questions & Answers - Galen What type of database is most appropriate when the rapid collection of data is required and often compiled concurrently with lifesaving measures? a. Complete b. Focused c. Follow-up d. Emergency d. Emergency An emergency database includes the rapid collection of data often obtained concurrently with lifesaving measures. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up on short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. A nurse precepting a student nurse asks, "What's the most important step in the critical-thinking process?" a. Clustering subjective and objective data b. Analyzing health data c. Using evidence-based assessment techniques d. Prioritizing health concerns c. Using evidence-based assessment techniques Evidence-based techniques are supported by research showing effectiveness of the technique that provides the safest and most current techniques to promote the health of patients. Clustering subjective and objective data is a step in the critical-thinking process, but is not the most important step. Analyzing health data is a step in the critical-thinking process, but is not the most important step. Prioritizing health concerns is a step in the critical-thinking process, but is not the most important step. What type of database is most appropriate for an individual who is admitted to a long-term care facility? a. Focused b. Complete c. Emergency d. Follow-up b. Complete A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up on short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. An emergency database includes a rapid collection of data often obtained concurrently with lifesaving measures. Which of the following is an example of objective data? a. A sore throat b. An earache c. Alert and oriented d. Dizziness c. Alert and oriented Objective data is what the health professional observes; level of consciousness and orientation are observations. Subjective data is what the person says about himself or herself during history taking. Which of the following is an example of subjective data? a. Blood glucose 126 md/dL b. Pain rated at 7 out of 10 c. Heart rate of 76 bpm d. Bruising on lower leg b. Pain rated at 7 out of 10 Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Blood glucose is measured by using a drop of blood placed on a test strip in a glucometer. Bruising is assessed by inspection. Heart rate is assessed by palpation of the radial artery or auscultated with a stethoscope when listening to heart sounds. A complete database is a. used to collect data rapidly and is often compiled concurrently with lifesaving measures. b. used to evaluate the cause or etiology of disease. c. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. d. used to perform a thorough or comprehensive health history and physical examination. d. used to perform a thorough or comprehensive health history and physical examination. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An emergency database is a rapid collection of data often obtained concurrently with lifesaving measures. A focused database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. Medical diagnoses are used to evaluate the cause or etiology of the disease. A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? a. Ineffective self-health management b. Impaired gas exchange c. Readiness for enhanced spiritual well-being d. Risk for infection b. Impaired gas exchange First-level priority problems are problems that are emergent, life-threatening, and immediate. Impaired gas exchange is an emergent and immediate problem. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Ineffective self-health management is an example of a third-level priority. Second-level priority problems are problems that are next in urgency; these problems require prompt intervention to forestall further deterioration. Risk for infection is an example of a second-level priority. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Wellness diagnoses are third-level priority problems. Which of the following actions/behaviors in the critical-thinking process are important for the novice nurse to remember? (Select all that apply.) a. Disregard initial cues b. Approach assessment with a nonjudgmental attitude c. Cluster associated assessment data d. Perform assessment in whatever manner works for you. e. Avoid making assumptions b, c, e The nurse should never make assumptions as they may bias data collection and selection of diagnoses. An important aspect to gain trust with the patient is to maintain a nonjudgmental attitude. Once all health assessment data has been collected, it is important to cluster signs and symptoms as this will help in the critical thinking and decision-making process regarding medical and nursing diagnoses. It also helps to categorize problems as the first, second, or third priority. The nurse should never disregard any cues. These are important in the critical thinking and diagnosis decision-making process. Novice nurses do not have enough experience to vary from the step-by-step process for health assessment data collection. As the nurse gains experience, he/she will learn when it's appropriate to vary the process. An example of subjective data is a. decreased range of motion. b. crepitation in the left knee joint. c. arthritis. d. left knee has been swollen and hot for the past 3 days. d. left knee has been swollen and hot for the past 3 days. Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpating. Arthritis is a medical diagnosis. An example of objective data is a. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion. b. a complaint of left knee pain. c. crepitation in the left knee joint. d. left knee has been swollen and hot for the past 3 days. c. crepitation in the left knee joint. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation. Subjective data is what the person says about himself or herself during history taking. While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following would most likely describe this patient's view of wellness? a. The phlegm will be replaced with dryness. b. The humors must be balanced. c. Good is hot. d. Evil is hot. b. The humors must be balanced. The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the balance of the humors. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. The four humors of the body include the blood, phlegm, black bile, and yellow bile; the humors regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. When completing a health assessment, which of the following actions most demonstrates cultural competence? a. Ask about family history of diseases. b. Ask about use of traditional, herbal, or folk remedies. c. Make sure the blood pressure cuff fits appropriately. d. Measure height and weight in a private room. b. Ask about use of traditional, herbal, or folk remedies. Failing to ask about use of traditional, herbal, or folk remedies could lead to significant drug interactions. Use of a private room is not necessary for all ethnic/cultural groups. All patients should be asked about family history of diseases. This is a necessary aspect for health assessment of all individuals. It is important to make sure the blood pressure fits appropriately for all patients. Spirituality is defined as a. a social group that claims to possess variable traits. b. participating in religious services on a regular basis. c. the process of being raised within a culture. d. a personal effort to find meaning and purpose in life. d. a personal effort to find meaning and purpose in life. Spirituality is a personal effort to find purpose and meaning in life. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Ethnicity pertains to a social group within the social system that claims to possess variable traits. Which of the following statements regarding language barriers and health care is true? a. English proficiency is associated with a lower quality of care. b. Patients with language barriers have a decreased risk for nonadherence to medication regimens. c. Standards have been identified that are important to eliminate health disparities. d. LEP is associated with a higher quality of care. c. Standards have been identified that are important to eliminate health disparities. Title VI of the Civil Rights Act of 1964 provides people with LEP access to health care; these individuals cannot be denied health care services. The National Standards for Culturally and Linguistically Appropriate Services in Health Care are important to implement in order to improve quality of care and eliminate health disparities. LEP is associated with a lower quality of care. English proficiency is associated with a higher quality of care. Patients with language barriers have an increased risk for nonadherence to medication regimens. What is the yin/yang theory of health? a. Health exists in the absence of illness. b. Health exists when all aspects of the person are in perfect balance. c. Health exists when physical, psychological, spiritual, and social needs are met. d. Health exists when there is optimal functioning. b. Health exists when all aspects of the person are in perfect balance. In the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance. In the hot/cold theory, health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. The biomedical model of Western tradition views health as the absence of disease. In the biomedical or scientific theory, high-level wellness (or health) exists with optimal functioning of the human body. Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? a. Congruence mechanism b. Heritage consistency c. Behavior theory d. Socialization experience b. Heritage consistency Heritage consistency theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage. Behavior theory or behaviorism is a learning theory. Carl Rogers described the concepts of congruence and incongruence as important ideas in his theory of personality and human development. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Which of the social determinants of health has the greatest influence on a person's health? a. Work environment b. Neighborhood c. Education d. Poverty d. Poverty The social determinants of health are interconnected and affect a person's health. But, research has consistently shown that poverty has the greatest influence on health status. Each culture has its own healers who usually a. own and operate specialty community clinics. b. cost less than traditional or biomedical providers. c. recommend folk practices that are dangerous. d. speak at least two languages. b. cost less than traditional or biomedical providers. Most healers cost significantly less than healers practicing in the biomedical or scientific health care system. Most healers speak the person's native tongue. Most healers make house calls. Most health practices used by folk healers are not dangerous and are usually harmless. Which of the following symptoms is greatly influenced by a person's cultural heritage? a. Food intolerance b. Hearing loss c. Pain d. Breast lump c. Pain Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain all are embedded in a cultural context. Hearing loss is more common in whites than in blacks. The incidence of breast cancer varies with different cultural groups. Food intolerance varies with different cultural groups. For example, lactose intolerance is common in African Americans, American Indians, and Asian Americans. When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the healthcare needs of others. These discrete areas include understanding of (Select all that apply.) a. his or her own heritage. b. cultural and ethnic values. c. the heritage of the health care system. d. the heritage of the nursing profession. e. the heritage of the patient. a, c, d, e Discrete areas of knowledge for cultural competence include understanding of one's own heritage, the heritage of the nursing profession, the heritage of the patient, and the heritage of the health care system. Understanding cultural and ethnic values is not an area of knowledge for cultural competence. When preparing the physical setting for an interview, the interviewer should a. stand next to the patient to convey a professional demeanor. b. conduct the interview at eye level and at a distance of 4 to 5 feet. c. reduce noise by turning the volume on the television or radio down. d. set the room temperature between 64° F and 66° F. b. conduct the interview at eye level and at a distance of 4 to 5 feet. Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet. The room temperature should be set at a comfortable level; a temperature between 64° F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment to reduce noise. The interviewer and the patient should be comfortably seated; standing communicates haste and assumes superiority. Which of the following statements made by the interviewer would be an appropriate response? a. "Tell me what you mean by 'bad blood.'" b. "If I were you, I would have the surgery." c. "I know just how you feel." d. "Why did you wait so long to make an appointment?" a. "Tell me what you mean by 'bad blood.'" "Tell me what you mean by 'bad blood'" is an appropriate communication technique referred to as seeking further clarification. "I know just how you feel" is an inappropriate communication technique referred to as false reassurance. "If I were you, I would have the surgery" is an inappropriate communication technique referred to as giving unwanted advice. "Why did you wait so long to make an appointment?" is an inappropriate communication technique referred to as using "Why" questions. While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation a. impedes further discussion. b. helps the nurse understand his or her own feelings in relation to the patient's verbal message. c. affects the nurse-physician relationship. d. helps the patient understand personal feelings in relation to his or her verbal message. d. helps the patient understand personal feelings in relation to his or her verbal message. Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient's personal feelings in relation to the patient's verbal message. The nurse-physician relationship is not the barrier to communication in this situation. The use of euphemisms to avoid reality or to hide feelings is known as a. avoidance language. b. distancing language. c. sympathetic language. d. ethnocentric language. a. avoidance language. Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior. When addressing a toddler during the interview, the health care provider should a. use detailed explanations. b. ask the child, before the caregivers, about symptoms. c. use nonverbal communication. d. use short, simple, concrete sentences. d. use short, simple, concrete sentences. A toddler's communication is direct, concrete, literal, and set in the present. The healthcare provider should use short, simple sentences with concrete explanations. For a younger child such as a toddler, the parent will provide all or most of the history. Nonverbal communication is the primary communication method for infants. Detailed explanations would be more appropriate for a school-age child, adolescent, or adult. Nonverbal communication is the primary form of communication for which group of individuals? a. Older adults b. Infants c. Preschoolers d. Adolescents b. Infants Nonverbal communication is the primary communication method for infants. Preschoolers' communication is direct, concrete, literal, and set in the present. Adolescents should be treated with respect; the nurse should use open, honest, professional communication. Older adults may need special considerations r/t physical limitations (e.g., adjusted pace to avoid fatigue, impaired hearing). Viewing the world from another person's inner frame of reference is called a. empathy. b. clarification. c. reflection d. sympathy a. empathy. Empathy means viewing the world from the other person's inner frame of reference. Reflection is repeating part of what the person has just said. Clarification is used to summarize the person's words or to simplify the words to make them clearer. Sympathy is a social affinity in which one person stands with another person, closely understanding his or her feelings. Parents or caregivers accompany children to the health care setting. Starting at years of age, the interviewer asks the child directly about his or her presenting symptoms. a. 11 b. 7 c. 9 d. 5 b. 7 School-age children (starting at age 7) have the verbal ability to add important data to the history. The nurse should interview the parent and child together, but when a presenting symptom or sign exists, the nurse should ask the child about it first and then gather data from the parent. An example of an open-ended question or statement is a. "Tell me about your pain." b. "You are upset about the level of pain, right?" c. "On a scale of 1 to 10, how would you rate your pain?" d. "I can see that you are quite uncomfortable." a. "Tell me about your pain." Open-ended questions and statements ask for narrative information; they state the topic to be discussed but only in general terms. "Tell me about your pain" encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen. "On a scale of 1 to 10, how would you rate your pain?"; "I can see that you are quite uncomfortable"; and "You are upset about the level of pain, right?" are closed or direct questions. Closed or direct questions and statements ask for specific information. This type of question or statement will elicit a short, one or two-word answer, a yes or no response, or a forced choice. The most appropriate introduction to use to start an interview with an older adult patient is a. "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." b. "David, I am here to ask you questions about your illness; we want to determine what is wrong." c. "Because so many people have already asked you questions, I will just get the information from the chart." d. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" a. "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." An older adult should be addressed by the last name; older adults may be offended by a younger person using their first names. The initial introduction should include the person's surname (unless a child) and the reason for the interview. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" is a closed-ended question. "Because so many people have already asked you questions, I will just get the information from the chart" does not allow for free expression of ideas. Which of the following is included in documenting a history source? a. Appearance, dress, and hygiene b. Documented relationship of support systems c. Reliability of informant d. Cognition and literacy level c. Reliability of informant The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history. A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about a. the patient's perception of pain. b. the nature or character of the headache. c. relieving factors. d. aggravating factors. d. aggravating factors. Aggravating factors are determined by asking the patient what makes the pain worse. To determine the patient's perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means. The nature or character calls for specific descriptive terms to describe the pain. Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help. The CAGE test is a screening questionnaire that helps to identify a. depression. b. excessive or uncontrollable drinking. c. unhealthy lifestyle behaviors. d. personal response to stress. b. excessive or uncontrollable drinking. CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. The "review of systems" in the health history is a. a short statement of general health status. b. an evaluation of past and present health state of each body system. c. a documentation of the problem as perceived by the patient. d. a record of objective findings. b. an evaluation of past and present health state of each body system. The purpose of the review of systems is to evaluate the past and present health state of each body system, to double check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. The reason for seeking care is a statement in the person s own words that describes the reason for the visit. This is typically known as a "chief complaint" or the reason for the health care visit. Objective data are the observations obtained by the health care professional during the physical examination. A short statement r/t the patient's general health status is typically included in the complete physical assessment record. When recording information for the review of systems, the interviewer must document a. "negative" under the system heading. b. the presence or absence of all symptoms under the system heading. c. objective data that support the history of present illness. d. physical findings, such as skin appearance, to support historic data. b. the presence or absence of all symptoms under the system heading. When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms; otherwise, it is unknown which factors were asked. Recording physical findings in the review of systems are incorrect; the review of systems is limited to the patient's statements or subjective data. Writing "negative" after the system heading is also incorrect because it would be unknown which factors were asked. Recording objective data in the review of systems is incorrect; the review of systems is limited to the patient's statements or subjective data. Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include a. education, financial status, and value-belief system. b. family role, interpersonal relations, social support, and time spent alone. c. stressors, coping mechanisms, and change in past year. d. exercise and activity, leisure activities, and level of independence. a. education, financial status, and value-belief system. Functional assessment measures a person's self-care ability. The areas assessed under the self esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. These areas are r/t the activity and exercise section of the functional assessment. These areas are r/t the interpersonal relationships and resources section of the functional assessment. These areas are r/t the coping and stress management section of the functional assessment. PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to a. the ability to perform activities of daily living (ADLs). b. substance use and abuse. c. pain presentation. d. severity of dementia. c. pain presentation. The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person's self-care ability including the ability to perform ADLs. The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to a. ask the patient if there is someone who could verify information. b. rephrase the same questions later in the interview. c. call a family member to confirm information. d. review previous medical records. b. rephrase the same questions later in the interview. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corroboration of information from another individual is not within the context of the present interview. This would occur outside the context of the interview. When taking a health history from an adolescent, the interviewer should a. ask every youth about the use of condoms. b. have at least one parent present during the interview. c. ask about violence and abuse before asking about alcohol and drug use. d. interview the youth alone with a parent in the waiting area. d. interview the youth alone with a parent in the waiting area. The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (r/t injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and What information is included in greater detail when taking a health history on an infant? a. Environmental hazards b. History of present illness c. Nutritional data d. Family history c. Nutritional data The amount of nutritional information needed depends on the child's age; the younger the child is, the more detailed and specific the data should be. The health history is adapted to include information specific for the age and developmental stage of the child (e.g., mother's health during pregnancy, labor, and delivery and the perinatal period). The developmental history and nutritional data are important for current health of infants and children. Dehydration and malnutrition can be manifestations of a. physical abuse b. intimate partner violence c. psychological abuse d. neglect d. neglect in older adults. Neglect in an older person can manifest with symptoms of dehydration and malnutrition. Neglect (physical) is defined as failure to provide basic goods and services such as food, shelter, health care, and medications. Intimate partner violence is identified by two types: physical or sexual violence (physical force) and psychological/emotional abuse or coercive tactics when there has been prior physical or sexual violence. Physical abuse is physical injury caused by intentional or unintentional harmful acts. Psychological abuse is defined as behaviors that result in mental anguish. Increased bruising and bleeding in older adults may be r/t which of the following? a. Ingestion of non-steroidal anti-inflammatory drugs b. A reduction in the integrity of blood vessels c. Thinning of the skin d. Decreased fluid intake a. Ingestion of non-steroidal anti-inflammatory drugs Certain medications such as non-steroidal anti-inflammatory drugs increase the risk for bruising or bleeding complications. Thinning of the skin in older adults increases the risk for skin breakdown and skin diseases. Blood vessels grow more rigid with age. Dehydration and decreased fluid intake may occur in older adults because of a decrease in thirst sensation, inability to obtain fluids r/t altered mobility, or neglect. Women and men who have been physically abused are most often abused by a. a man with a substance use problem. b. an intimate male partner. c. a known sex offender. d. a man convicted of a serious crime. b. an intimate male partner. Approximately 33% of women and 25% of men report being abused by an intimate partner in the United States (i.e., girlfriend/boyfriend, spouse, sexual partner). An extremely important part of the history and examination in situations of intimate partner violence or older adult abuse is the a. mental status examination. b. family genogram. c. history of the present illness. d. skin assessment. a. mental status examination. An extremely important part of the history and examination in cases of intimate partner violence or older adult abuse is a mental status examination, as abuse victims have significantly more depression, suicidality, post-traumatic stress disorder, and substance abuse. A family genogram is not as important as the mental status examination, skin assessment, and history. It is also important to assess and document prior abuse, including intimate partner violence, physical and sexual abuse, and rapes of all kinds. The skin assessment is also an important part of the history and examination. The health care system may help abused women by a. providing financial and supportive services. b. estimating the ages of bruises. c. providing shelter from the abusive individual. d. identifying abuse in the early stages. d. identifying abuse in the early stages. The health care system can be an extremely important early point of contact. Uncovering abuse in early stages may stop the pattern of violence and avoid or minimize long-term health problems. The health care system does not provide shelter for abused women. The health care system does not provide financial assistance or supportive services for abused women. Estimation of the age of bruises should be avoided because evidence does not support the ability to date a bruise. Abused women have been found to have significantly more health problems, including a. cardiovascular disease. b. chronic anemia. c. chronic pain. d. cancer. c. chronic pain. Abused women have been found to have significantly more injuries. Also, abused women have more chronic health problems including neurologic, gastrointestinal, and gynecologic symptoms and chronic pain. Abused women do not have a higher incidence of cardiovascular disease. Abused women do not have a higher incidence of cancer. Abused women do not have a higher incidence of chronic anemia. The nurse caring for an older adult suspects older adult abuse. Which action is appropriate? a. Confront the caregivers about the suspicion of abuse. b. Collect proof of abuse before notifying the authorities. c. Report the abuse if the older adult gives permission. d. Notify the authorities of the suspected older adult abuse. d. Notify the authorities of the suspected older adult abuse. The nurse is a mandatory reporter of older adult abuse and should notify the authorities of suspected older adult abuse. The nurse does not need proof of abuse before calling the authorities. The nurse should not confront the caregivers if older adult abuse is suspected. The nurse does not need permission from the older adult before calling the authorities. The nurse is assessing a person who is a suspected victim of abuse. When documenting assessment data, which of the following is the most important concept for the nurse to remember? (Select all that apply.) a. Words used when documenting should be sanitized. b. It must be detailed and unbiased. c. Speculation on the cause of injury should be included. d. Use the exact terms the abused person uses to describe sexual organs. e. Quotation marks should be used for severe threats of harm. b, d, e Documentation should be non-biased and include specific details, especially when documenting signs of physical abuse. Measurements, color, and other characteristics are important to document as specifically as possible and should include photographic documentation. Verbatim documentation of reported perpetrator's threats can be useful in future court proceedings. Using exact terms and asking for clarification if the nurse is unsure what the person means is important. When quoting or paraphrasing what the abused person has said, do not sanitize the words. The nurse should never speculate regarding the cause of signs/symptoms. Every time the nurse documents health assessment data, he/she must only document what they hear or assess through inspection, palpation, percussion, and auscultation. Opinions or information not specific to assessment findings should never be included in documentation. A woman seeks medical attention for a cut made by a knife during a physical assault. The health care provider would document the cut as an a. incision. b. ecchymosis. c. avulsion. d. abrasion. a. incision. An incision is a cut or wound made by a sharp instrument. Ecchymosis is a hemorrhagic spot or blotch in the skin or mucous membrane that forms a non-elevated, rounded or regular, blue or purplish patch. An avulsion is the tearing away of a structure or part. An abrasion is a wound caused by rubbing the skin or mucous membrane. To examine a toddler, the nurse should a. allow the child to sit on the parent's lap. b. ask the child to decide whether parents or siblings should be present. c. remove the child's clothing at the beginning of the examination. d. perform the assessment from head to toes. a. allow the child to sit on the parent's lap. A toddler should be sitting up on the parent's lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child who is 11 or 12 years old to decide whether parents or siblings should be present. The sequence of the examination for a toddler should start with nonthreatening areas first; save distressing procedures such as assessment of the head, ears, nose, or throat for last. Amplitude is a. the intensity (soft or loud) of sound. b. the number of vibrations per second. c. the length of time the note lingers. d. the subjective difference in a sound's distinctive overtones. a. the intensity (soft or loud) of sound. Amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference owing to a sound's distinctive overtones. The dorsa of the hands are used to determine a. temperature. b. fine tactile discrimination. c. position of an organ. d. vibration. a. temperature. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration. A grasping action of the fingers and thumb is the best way to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination. Deep palpation is used to a. elicit deep tendon reflexes. b. evaluate surface characteristics. c. determine the density of a structure. d. identify abdominal contents. d. identify abdominal contents. Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note. Fine tactile discrimination is best achieved with the a. back of the hands and fingers. b. fingertips. c. base of the fingers. d. opposition of the fingers and thumb. b. fingertips. The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration. An ophthalmoscopic examination is an examination of the a. pharynx. b. nasal turbinates. c. inner ear. d. internal structures of the eye. d. internal structures of the eye. An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares. Which of the following is considered when preparing to examine an older adult? a. Avoid physical touch to avoid making the older adult uncomfortable. b. Confusion is a normal, expected finding in an older adult. c. Be aware that loss will result in poor coping mechanisms. d. Base the pace of the examination on the patient's needs and abilities. d. Base the pace of the examination on the patient's needs and abilities. The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging. When performing percussion, the examiner a. taps fingertips over bony processes. b. strikes the stationary finger at the distal interphalangeal joint. c. strikes the flank area with the palm of the hand. d. strikes the stationary finger at the proximal interphalangeal joint. b. strikes the stationary finger at the distal interphalangeal joint. To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed). At the end of the examination, the examiner should a. compare objective and subjective data for discrepancies. b. have findings confirmed by another provider. c. review the findings with the patient. d. complete documentation before leaving the examination room. c. review the findings with the patient. At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination. The examiner should use hand-washing instead of an alcohol-based hand rub a. if the patient is HIV positive. b. if the patient has an infection with Clostridium difficile. c. if the patient has an infection with Mycobacterium tuberculosis. d. if the patient has an infection with hepatitis B virus. b. if the patient has an infection with Clostridium difficile. The examiner should use the mechanical action of soap-and-water hand-washing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV. The nurse documents the following findings for the behavioral portion of the general survey assessment, "patient demonstrates flat affect, lack of eye contact, hair not brushed, and strong body odor". The nurse should be concerned that the patient is which of the following? a. Depression b. Bulimia c. Dysarthria d. Seizures a. Depression Flat affect, lack of eye contact, unkempt appearance (hair not brushed), and smelling of body odor are common warning signs that the patient may be depressed. Dysarthria is unclear articulation of speech commonly associated with a stroke or a speech disorder. A person with a seizure disorder may have altered affect or eye contact, but may not demonstrate an unkempt appearance. A person with bulimia may have altered mood, affect, or facial expression, but typically not have altered dress or personal hygiene. An adult with a body mass index (BMI) less than 18.5 kg/m2 is considered which of the following? a. Underweight b. Obesity c. Normal weight d. Overweight a. Underweight A person with a body mass index (BMI) less than 18.5 kg/m2 is classified as underweight. Classification of obesity is a body mass index (BMI) of 30 to 39.9 kg/m2. Classification of normal weight is a body mass index (BMI) of 18.5 to 24.9 kg/m2. Classification of overweight is a body mass index (BMI) of 25 to 29.9 kg/m2. The general survey consists of four distinct areas. These areas include a. gait, range of motion, mental status, and behavior. b. level of consciousness, personal hygiene, mental status, and physical condition. c. physical appearance, body structure, mobility, and behavior. d. mental status, speech, behavior, and mood and affect. c. physical appearance, body structure, mobility, and behavior. The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition. The nurse is completing a general survey assessing the level of consciousness of a person. Which of the following findings are expected in this assessment? a. No signs of acute distress are present b. Facial features symmetric with movement c. Patient appears drowsy and is having difficulty answering questions. d. Patient is alert and oriented to person, place, time, and situation. d. Patient is alert and oriented to person, place, time, and situation. The normal/expected findings for level of consciousness includes: alert and oriented to person, place, time, and situation along with patient attends to and appropriately responds to questions. A patient who is drowsy and having difficulty answering questions is demonstrating decreased level of consciousness and should be assessed further. No signs of acute distress are the expected findings when the nurse assesses overall appearance. Facial features symmetric are expected findings when completing a general survey assessing physical appearance—facial features. Data collection for the general survey begins a. at the beginning of the physical examination. b. at the first encounter. c. while taking vital signs. d. during the mental status examination. b. at the first encounter. The general survey is initiated at the first encounter with the patient. Which of the following assessments should be included as part of the body structure portion of the general survey? a. Sexual development, skin color, and overall appearance b. Gait and range of motion c. Facial expression, speech pattern, and dress d. Stature, nutrition, and symmetry d. Stature, nutrition, and symmetry When completing the body structure assessment portion of the general survey, the nurse should assess stature, nutrition, symmetry, posture, position, and for physical deformities. Sexual development, skin color, and overall appearance are included in physical appearance portion of the general survey assessment. Gait and range of motion are included as part of the mobility portion of the general survey assessment. Facial expression, speech pattern, dress, mood and affect, and personal hygiene should be included in the behavior portion of the general survey assessment. Endogenous obesity is a. characterized by evenly distributed excess body fat. b. due to inadequate secretion of cortisol by the adrenal glands. c. caused by excess adrenocorticotropin (ACTH) production by the pituitary gland. d. a result of excessive secretion of growth hormone in adulthood. d. caused by excess adrenocorticotropin (ACTH) production by the pituitary gland. Endogenous obesity is caused by either the administration of adrenocorticotropin or excessive production of adrenocorticotropin by the pituitary. Adrenocorticotropin stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood. Physical appearance includes statements that compare appearance with a. mood and affect. b. nutrition. c. gait. d. stated age. d. stated age. Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition. Which of the following would be most appropriate when weighing an infant? a. If the infant can sit up, he/she can be weighed on a standard upright scale. b. The infant should be weighed undressed on a platform-type scale. c. It's okay to weigh the infant fully dressed. d. Weigh the mother then have her hold the infant and subtract the mother's weight from the result. b. The infant should be weighed undressed on a platform-type scale. Infants should be weighed undressed on a platform-type scale. A digital scale is preferred as they are usually more accurate. Using the process of weighing the mother then subtracting her weight after weighing her holding the infant, is an inaccurate procedure. Weight measurements of infants and children must be accurate to appropriate assess their growth patterns. In order to obtain the most accurate weight measurement of an infant, they should be weighed without clothes or diaper. It is inappropriate to weigh an infant using an upright scale. A platform-type scale placed on a counter is the safest and most accurate way to measure an infant's weight. The nurse is completing a general survey for an older adult and notices the patient demonstrates a wider gait with short, uneven steps. Which of the following would be the most important action of the nurse? a. Ask another nurse to assess the patient. b. Refer the patient to a geriatric health care specialist. c. Notify the physician immediately. d. Document this as normal findings. d. Document this as normal findings. An older adult with a wider gait with short, uneven steps is a normal finding. There is no need to immediately notify the physician since these are normal findings for an older adult. There is no need to refer the patient to a geriatric health care specialist since these are normal findings. Unless the nurse is a novice and this is the first time he/she is assessing an older adult, there is no need for a second opinion. Which of the following is a normal range for a patient's temperature measured using an oral thermometer? a. 37.5° C to 39.2° C b. 35.8° C to 37.3° C c. 36.2° C to 38.2° C d. 34.0° C to 34.9° C b. 35.8° C to 37.3° C This is the correct range for oral temperature. This range is the expected range for temperature measured using a rectal thermometer. A patient with an oral temperature in this range should be evaluated for other signs of hyperthermia (increased fever). An oral temperature less than 36.0° C is considered hypothermia. The Doppler technique a. is used to assess the apical pulse. b. amplifies Korotkoff sounds during blood pressure measurement. c. measures arterial oxygenation saturation. d. provides an easy and accurate measurement of the diastolic pressure. b. amplifies Korotkoff sounds during blood pressure measurement. The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. A stethoscope is used to assess an apical pulse. The systolic blood pressure is more easily identified with the Doppler technique than the diastolic pressure. A pulse oximeter measures arterial oxygenation saturation. The tympanic membrane thermometer (TMT) a. senses the infrared emissions of the cerebral cortex. b. provides an accurate measurement of core body temperature. c. accurately measures temperature in 20 to 30 seconds. d. is not used in unconscious patients. b. provides an accurate measurement of core body temperature. The TMT accurately measures core body temperature. The TMT senses the infrared emissions of the tympanic membrane; the tympanic membrane shares the same vascular supply that perfuses the hypothalamus. The TMT is used with unconscious patients or patients in the emergency department, recovery areas, and labor and delivery units. The temperature is displayed in 2 to 3 seconds. An adult patient's pulse is 46 beats per minute. The term used to describe this rate is a. weak and thready. b. tachycardia. c. sinus dysrhythmia. d. bradycardia. d. bradycardia. A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus dysrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle. Which of the following respiratory rates recorded for an infant without chronic illness would require further interventions and assessment by the nurse? a. 27 b. 45 c. 35 d. 30 b. 45 The nurse would need to complete further assessments and notify the physician for a respiratory rate of 45 breaths per minute. The normal range for respirations for an infant (up to 1 year) is 24 to 38 breaths per minute. Which technique would the nurse use to non-invasively assess arterial oxygen saturation? a. Arterial blood gas b. Pulse oximeter c. Blood Pressure d. Respiratory rate b. Pulse oximeter The pulse oximeter is a noninvasive method to assess SpO2. Respiratory rate is only a measure of the rate of a person's breathing, not SpO2. Blood pressure is an assessment of the force of blood pushing against the side of the vessel, not SpO2. Arterial blood gas is an invasive measure to assess oxygen saturation. Which of the following factors control a person's blood pressure? (Select all that apply.) a. Cardiac output b. Age c. Emotions d. Viscosity e. Vascular resistance a, d, e Factors that control blood pressure include: cardiac output, vascular resistance, volume, viscosity, and elasticity of arterial walls. Blood pressure varies, but is not controlled by age, gender, race, diurnal rhythm, weight, exercise, emotions, and stress. A common error in blood pressure measurement is a. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. b. taking the blood pressure in an arm that is at the level of the heart. c. deflating the cuff about 2 mm Hg per heartbeat. d. using a blood pressure cuff whose bladder length is 80% of the arm circumference. a. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure r/t venous congestion in the forearm. The patient's arm should be positioned at the level of the heart when obtaining a blood pressure measurement. The cuff should be deflated at a rate of 2 mm Hg per heartbeat. The blood pressure cuff bladder length should be about 80% of the arm circumference. To perform an accurate assessment of respirations, the examiner should a. count for 30 seconds after completing a pulse assessment and multiply by two. b. inform the person of the procedure and count for 1 minute. c. assess respirations for a full 2 minutes if an abnormality is suspected. d. count for 15 seconds while keeping fingers on the pulse and then multiply by four. a. count for 30 seconds after completing a pulse assessment and multiply by two. Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. Patients have conscious control over respirations; the examiner should not mention that respirations will be counted. Avoid counting respirations for 15 seconds because the results can vary +4 or −4 with such a small number. Respirations should be counted for 1 minute if abnormalities are suspected. The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? a. Anxiety b. Shock c. Bleeding d. Dehydration a. Anxiety A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise. A weak, thready pulse may reflect a decreased stroke volume, as with dehydration. A weak, thready pulse may reflect a decreased stroke volume, as with shock. A weak, thready pulse reflects a decreased stroke volume, as with bleeding. The nurse should recognize that categories such as ethnicity, gender, religion illustrate which concept? subcultures When performing a physical assessment, what technique should the nurse always perform first? inspection What part of the stethoscope do you use to listen fore high pitched sounds? diaphragm While performing the physical examination, the nurse shares information and briefly teaches the patients. Why does the nurse do this? to build rapport and increase the patients confidence in the examiner When assessing a patient's pulse, the nurse would also notice which of these characteristics? the force of the pulse What describes EBP EBPm emphasizes the use of best evidence with the clinicians experience What do the patients record, lab studies, objective and subjective data combine to form? database What is a focused or problem centered history? patient in an outpatient clinic that has cold and influenza like symptoms What data should the nurse collect during the interview portion of a health assessment? subjective what does the review of systems provide the nurse? information regarding health promotion practices During an examinaton, the nurse notices a patterned injury on a patient back. What would cause this injury? whipping from an extension cord As a mandatory reporter of older adult abuse, which must be present before a nurse would notify the authorities? suspicion of older adult abuse/neglect A patient states the he is nauseous and feels hot. Is this subjective or objective data? Subjective data Which critical thinking skill helps the nurse see relationships among the data? Clustering related cues What is formulated by a nurse using diagonistic reasoning? diagnostic hypothesis What are the components of holistic health? Views the mind, body, and spirit as interdependent A 2.5cm scar on the right lower forearm is an example of subjective or objective data? Objective data A nurse is making an initial home visit for a patient who has many chronic medical problems. What type of database is most appropriate to collect in this setting? A complete health database because of the nurses primary responsibility for monitoring the patients health A patient is brought by ambulance to the ED with multiple traumas recieved in an automobile accident. He is A&O, but his injuries are quite severe. How would the nurse proceed with data collection? simultaneously ask history questions while performing the examination and initiating life-saving measures A 16 year old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? Be totally honest with him, even if the information is unpleasant