Interview
Which type of question is preferred when obtaining a health history?
A. Leading questions
B. Yes/No questions
C. Open-ended, neutral questions
D. Questions that suggest the expected answer
C. Open-ended, neutral questions
During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?
“My stomach hurts. Hurts, spurts, burts.”
“Kiss, wood, reading, ducks, onto, maybe.”
“I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.”
“Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
“Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
A patient admits, "I know drinking is causing problems, but I can't seem to stop."
Which response by the nurse is most therapeutic?
A. "You need to make better choices."
B. "You should stop drinking immediately."
C. "Tell me more about the problems you've been experiencing."
D. "At least you recognize that you have a problem."
C. "Tell me more about the problems you've been experiencing."
The nurse observes a patient's skin color, posture, facial expression, and overall appearance.
What assessment technique is being used?
A. Palpation
B. Percussion
C. Inspection
D. Auscultation
C. Inspection
When assessing an older adult, the nurse would recognize that which vital sign changes occur with aging?
1-Widened pulse pressure
2-Increase in body temperature
3-Increase in pulse rate
4- Decrease in diastolic blood pressure
1-Widened pulse pressure
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
Man with a hearing impairment who has an interpreter with him who came in for a follow-up blood pressure check
Man who came in with his wife who was just diagnosed with lung cancer
Well-adjusted adolescent who came in for a sports physical
Recovering alcoholic who came in for a basic physical examination
Man who came in with his wife who was just diagnosed with lung cancer
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient’s tests of cognitive function?
Will be oriented to place and person, but the patient may not be certain of the date.
May show evidence of some clouding of his level of consciousness.
Will state, “I am so relieved to be out of intensive care.”
May display some disruption in thought content.
Will be oriented to place and person, but the patient may not be certain of the date.
Nurse observes a patient that is somnolent with RR 6/min with pinpoint pupils, what did the patient overdose from?
Narcotics
When performing an assessment of the abdomen, which sequence should the nurse use?
A. Palpation → Percussion → Auscultation → Inspection
B. Inspection → Palpation → Percussion → Auscultation
C. Inspection → Auscultation → Percussion → Palpation
D. Auscultation → Inspection → Palpation → Percussion
C. Inspection → Auscultation → Percussion → Palpation
The nurse notices that a colleague is preparing to check the blood pressure of a patient who is cachectic by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?
1- Yield a falsely high blood pressure
2- Vary as a result of the technique of the person performing the assessment
3- Be the same, regardless of cuff size
4- Yield a falsely low blood pressure
4- Yield a falsely low blood pressure
A patient has just been diagnosed with diabetes and says,
"My life is over. I'll never be able to eat the foods I love again."
Which nurse's response is the best example of therapeutic communication?
A. "You shouldn't feel that way. Many people live with diabetes."
B. "Everything will be okay. Talk with a nutritionist"
C. "It sounds like you're feeling overwhelmed by this diagnosis. Tell me more about what's worrying you
C. "It sounds like you're feeling overwhelmed by this diagnosis. Tell me more about what's worrying you
A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first?
Cognitive abilities
Level of consciousness
Affect and mood
Memory and affect
Level of consciousness
A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop “cold turkey.” He asks the nurse, “What symptoms can I expect if I do this?” Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? (Select all that apply.)
1-Hunger
2- Sweating
3- Sleepiness
4- Headaches
5- Nervousness
6- Restlessness
1-Hunger
4- Headaches
5- Nervousness
6- Restlessness
The nurse hears a high-pitched musical sound while the patient is exhaling.
What finding is the nurse documenting?
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
D. Wheezes
While measuring a patient’s blood pressure, the nurse would recall that which is a factor that influences a patient’s blood pressure?
1- Pulse pressure
2-Peripheral vascular resistance
3- Pulse rate
4- Vascular output
2-Peripheral vascular resistance
The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?
“While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?”
“It would help to interview the three of you together.”
“While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”
“Please stay during the interview; you can answer for her if she does not know the answer.”
“While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”
A patient says,
"I hear voices telling me that I am worthless."
What is the nurse's priority action?
A. Tell the patient the voices are not real.
B. Change the subject.
C. Assess whether the voices are telling the patient to harm themselves or others.
D. Leave the patient alone to reduce stimulation
C. Assess whether the voices are telling the patient to harm themselves or others.
Nurse observes a patient in the ER that is sweating, has coarse tremor of the hands and transient hallucinations. What is the patient withdrawing from?
alcohol
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How would the nurse proceed with the assessment?
1-Obtain a thorough history and physical assessment from the patient’s family member.
2- Examine the body areas appropriate to the problem and perform the rest of the complete assessment after the problem has resolved.
3- Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
4-Immediately perform a complete history and physical assessment to obtain baseline information.
2- Examine the body areas appropriate to the problem and perform the rest of the complete assessment after the problem has resolved.
Patient is being seen in the clinic for reports of "fainting episodes that started last week". Which vital sign would be the most appropriate to check?
Blood pressure- lying, sitting standing positions
The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? (Select all that apply.)
1- “How often do the headaches occur?”
2- “On a scale of 1 to 10, how bad is the pain?”
3- “Do you have any family history of headaches?”
4- “Where is the headache pain?”
5- “Did you have these headaches as a child?”
6- “What makes the headaches feel better?”
1- “How often do the headaches occur?”
2- “On a scale of 1 to 10, how bad is the pain?”
4- “Where is the headache pain?”
6- “What makes the headaches feel better?”
The nurse is providing instructions to newly hired graduates for the mini–mental state examination (MMSE). Which statement best describes this examination?
This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
The MMSE is a good tool to evaluate mood and thought processes.
Scores below 30 indicate cognitive impairment.
The MMSE is a useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.
This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness. The maximum score on the test is 30; people with normal mental status average 27. Scores between 24 and 30 indicate no cognitive impairment. It evaluates cognitive functioning, not mood or thought processes
Name two signs/symptoms the nurse expects in a patient experiencing opioid withdrawal?
Yawning, sweating, diarrhea, muscle aches, and dilated pupils
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?
1- Palpation with the nurse’s palm of the hand
2- Diaphragm of the stethoscope
3- Electrocardiogram
4- Bell of the stethoscope
4- Bell of the stethoscope
When assessing the quality of a patient’s pain, the nurse would ask which question?
1- “Is it a sharp pain or dull pain?”
2- “Is the pain a stabbing pain?”
3- “What does your pain feel like?”
4- “When did the pain start?”
3- “What does your pain feel like?”
To assess the quality of a person’s pain, the patient is asked to describe the pain in his or her own words. Asking when the pain started does not assess the quality of pain. To assess the quality of a person’s pain, the patient is asked to describe the pain in his or her own words, not providing descriptions of types of pain for the patient to confirm or deny.