Professional Documents
Culture Documents
Midterm
Midterm
Midterm
8. What is the minimum amount of time that should be allotted for a complete health
history?
A) 15 minutes
B) 30 minutes
C) 45 minutes
D) 60 minutes
10. Which setting is the best place to gather data for a health history?
A) Waiting room
B) Hallway
C) Patient's room
D) On the way to surgery
11. Choose the best body position for the nurse to have while obtaining the health history:
A) Leaning over the bed.
B) Standing at the bedside.
C) Sitting on the bed.
D) Sitting on a chair at the bedside.
13. The “P” in the mnemonic “PQRST” stands for:
A) Pain.
B) Purpose.
C) Precipitating.
D) Pinpoint.
14. An appropriate tool to use when assessing level of pain in young children is to:
A) Ask them to point to where it hurts.
B) Ask them to describe the pain on a scale from 0 to 10.
C) Ask them to draw a picture of the hurt.
D) Ask then to use a FACES scale to describe the pain.
18. Asking a patient about her or his occupation is important to assist in identifying:
A) Insurance coverage.
B) Possible health risks.
C) Genetic mutations.
D) Developmental tasks.
20. All of the following guidelines apply when documenting a health history except:
A) Being accurate and objective.
B) Writing in complete sentences with proper punctuation.
C) Using standard medical abbreviations.
D) Dating and signing documentation.
15. When describing the expansion of the depth and scope of nursing assessment over the
past several decades, what would the nurse identify as being the primary force?
A) Documentation
B) Informatics
C) Diversification
D) Technology
16. A group of nurses is reviewing information about the potential opportunities for nurses
who have advanced assessment skills. When discussing phenomena that have contributed to
these increased opportunities, what should the nurses identify?
A) Expansion of health care networks
B) Decrease in client participation in care
C) The shrinking cost of medical care
D) Public mistrust of physicians
17. A nurse has documented the findings of a comprehensive assessment of a new client.
What is the primary rationale that the nurse should identify for accurate and thorough
documentation?
A) Guaranteeing a continual assessment process
B) Identifying abnormal data
C) Assuring valid conclusions from analyzed data
D) Allowing for drawing inferences and identifying problems
18. A nurse has received a report on a client who will soon be admitted to the medical unit
from the emergency department. When preparing for the assessment phase of the nursing
process, what should the nurse do first?
A) Collect objective data.
B) Validate important data.
C) Collect subjective data.
D) Document the data.
23. A nurse is completing an assessment that will involve gathering subjective and objective
data. Which assessment technique will best allow the nurse to collect objective data?
A) Inspection
B) Therapeutic communication
C) Interviewing
D) Active listening
2. Which of the following statements best describes the assessment step in the nursing
process?
A) Data are analyzed to identify actual and potential health problems.
B) This step sets the tone for the rest of the nursing process.
C) This step involves setting goals and outcomes.
D) The patient's response is assessed based on set outcome criteria.
4. Which step ensures that the assessment data are correct before proceeding with the
nursing process?
A) Clustering data
B) Validation
C) Implementation
D) Evaluation
8. Nursing actions are carried out during which step of the nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
9. The nursing process uses which of the following approaches to problem solving?
A) Trial-and-error
B) Reflexive thinking
C) Intuition
D) Scientific method
10. What types of skills are most important in performing a physical assessment?
A) Psychomotor
B) Interpersonal
C) Ethical
D) Affective
17. During the initial assessment interview, the nurse should allow for how much personal
space?
A) 0–18 inches
B) 18 inches–3 feet
C) 4–12 feet
D) 12 or more feet
18. When utilizing an interpreter while taking the history, the nurse should realize:
A) The interview may take additional time.
B) Confidential content may not be covered.
C) Relatives are the best interpreters.
D) Children are the best interpreters.
19. A 25-year-old female patient complains of acute pain in her abdomen. The nurse
touches her arm and she recoils. The nurse should recognize that touch:
A) Increases pain sensation.
B) Is offensive to most individuals.
C) Is very personal and should be avoided.
D) Is interpreted differently by each culture.
20. Restating the patient's main idea demonstrates that the nurse:
A) Is unclear about the patient's main complaint.
B) Is hard of hearing.
C) Is giving instructions.
D) Understands the patient's concerns.
22. Joe Keller, age 70, is brought to the emergency room with the chief complaint of chest
pain for the past hour. Which question would be most useful in eliciting Mr. Keller's chief
complaint?
A) Are you having chest pain?
B) Is the chest pain sharp?
C) Does the chest pain radiate to your arm?
D) What does the pain feel like?
23. What is the most effective way to assess the severity of Mr. Keller's pain?
A) Ask him what it feels like.
B) Ask him what makes it feel better.
C) Ask him to rate the pain on a scale of 0 to 10, with 10 being the worst.
D) Ask him what makes it feel worse.
24. Which type of question would be most effective in obtaining a patient's perception of
his or her problem?
A) Open-ended question
B) Closed-ended question
C) Leading question
D) Probing question
25. During the interview, a patient states that she or he doesn't use many drugs. The nurse's
best response to this statement is:
A) “Tell me about the drugs you use now.”
B) “To some people, six or seven is not many.”
C) “Do you mean legal drugs or illegal ones?”
D) “What kind of drugs are you talking about?”
26. During the interview, a patient tells the nurse that he rarely sleeps more than 4 hours a
night and hasn't experienced any problems because of lack of sleep. An appropriate response
by the nurse is:
A) “Okay, I see.”
B) “That can't be true, is it?”
C) “That's awful. Anyone needs more sleep than that.”
D) “Did I understand that you sleep only 4 hours every night?”
27. During a routine examination, your client expresses concern about breast cancer. You
determine that she has health-seeking behaviors related to breast cancer. Which phase of the
nursing process does this statement describe?
A) Assessment
B) Planning
C) Nursing diagnosis
D) Implementation
28. What type of nursing diagnosis would need further supportive data for validation?
A) Actual
B) Impending
C) Potential
D) Possible
29. A collaborative diagnosis differs from others in that a collaborative diagnosis needs:
A) Further data to support diagnosis
B) Both medical and nursing interventions
C) Only medical interventions
D) Preventative measures
32. During which phase of the nursing process do you develop patient outcomes?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Implementation
5. A nurse has gathered the necessary equipment for the physical assessment of an adult
client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which
measurement?
A) Mid-arm circumference
B) Client's height
C) Skin lesion size
D) Pupillary size
6. The nurse is preparing to assess an older adult client's near vision. The nurse would use
which piece of equipment for the assessment?
A) Newspaper
B) Snellen E chart
C) Ophthalmoscope
D) Penlight
8. The nurse is examining an older adult client. The nurse would use a goniometer for
which assessment?
A) Extremity edema
B) Joint flexion/extension
C) Two-point discrimination
D) Vibratory sensation
10. The nurse is preparing to perform a physical examination on a female client who has
been transferred to the medical unit from the emergency department. The nurse should begin
the collection of objective data with which examination?
A) Head and neck examination
B) Palpation of lymph nodes
C) Breast examination
D) Vital signs
5. The correct method for taking an adult's temperature, using a tympanic thermometer, is
to:
A) Pull the helix up and back.
B) Pull the helix down and back.
C) Pull the helix horizontally to straighten the ear canal.
D) Not move the canal out of normal anatomical position.
6. The average length of a stethoscope is 22 to 27 inches. If the tubing is longer, the sound
will be:
A) Louder.
B) Softer.
C) Higher pitched.
D) Lower pitched.
1. A nurse is completing the intake assessment of an older adult who has just relocated to
a long-term care facility. Which nursing action would be most important to ensure accurate
data when gathering the resident's information?
A) Documenting the data
B) Validating the data
C) Identifying client support systems
D) Determining client needs
2. A nurse is assessing a female client whose worsening sciatica has prompted her to seek
care. Which client statement would the nurse most likely need to validate?
A) “I don't generally have problems with pain.”
B) “I feel very weak and tired right now.”
C) “I've had two caesarean deliveries.”
D) “My mother died of breast cancer in her 60s.”
5. A nurse has documented the nursing history and physical examination of a client. This
health information is best described as which of the following?
A) Subjective data and objective data
B) Interpretation and inference
C) Observation and inspection
D) Data and results
2. Which section of the health history can be documented as a genogram?
a. Chief complaint
b. Past health history
c. Family history
d. Current health status
4. When obtaining a family history, who does not need to be included in the genogram?
a. Spouse
b. Siblings
c. In-laws
d. Aunts/uncles
9. What part of the health history identifies the source and reliability?
a. Biographical data
b.Current health status
c. Chief complaint
d.Past medical history
1. What would you tell a patient who is about to undergo FBS test?
a. The patient should fast for 8 hours before the test. All diabetes mellitus
(DM) medications are withheld until the test is completed.
b. The patient should eat a regular meal but refrain from ingesting sugarbeverages.
c. The patient should eat a regular meal, including ingesting sugarbeverages.
d. The patient should eat a bland meal and refrain from ingesting sugarbeverages.
32. Aside from renal failure, what would a high BUN level indicate?
a. Shock
b. Urinary tract blockage
c. Respiratory tract bleeding
d. All of the above
34. Why should you assess if the patient has taken antibiotics before testing for
potassium?
a. Taking antibiotics indicates that the patient has a bacterial infection.
b. Some antibiotics contain potassium.
c. Patients who take antibiotics always have higher than normal levels of potassium.
d. Patients might vomit during the test.
38. Why is not the Mantoux skin test used to diagnose tuberculosis?
a. A positive result indicates that the patient has developed antibodies to
Mycobacterium tuberculosis antigen possibly from a previous exposure to M tuberculosis.
b. A negative result indicates that the patient has not developed antibodies to M tuberculosis
antigen; however the immune system can take up to 10 weeks to develop the antibodies
following the infection.
c. Diagnosis is made using an X-ray.
d. All of the above.
56. Why is a pillow placed under the patient’s shoulders during a thyroid gland
biopsy?
a. This prevents the patient from moving during the procedure.
b. This causes the thyroid gland to be pushed backward.
c. This causes the thyroid gland to be pushed forward.
d. This assures that the patient’s airway is open during the procedure.
1. a. The patient fasts for 8 hours. All DM medications are withheld until the
test is completed.
2. b. Rest for 30 minutes.
3. d. All of the above.
4. a. Avoid eating and drinking except for water 12 hours before the test is
administered.
5. d. All of the above.
6. a. Assesses bladder function.
7. a. Glucophage may react with contrast material.
8. d. All of the above.
9. a. It removes the outer layer of skin enabling new skin to grow.
10. a. Administer a sedative per order.
11. b. By using the salivary gland scan.
12. a. Troponin and CPK-MB.
13. a. Renin.
14. a. The carcinoembryonic antigen is normally present during fetal
development and is terminated at birth. It is present if there is a tumor.
608 Nursing Lab and Diagnostic Tests Demystifi ed
15. a. The patient has arthritis.
16. c. It should be discarded.
17. c. To determine blood supply to the brain.
18. d. All of the above.
19. b. May have Tay-Sachs disease.
20. b. Coumadin decreases coagulation time, thereby increasing the risk of
bleeding during the procedure.
21. c. The amount of thyroxine that is attached to globulin and that is not
bound to globulin.
22. a. FSH test.
23. c. To encourage healing.
24. c. Prolactin levels are normally high when the patient fi rst awakens.
25. c. Bacterial infection.
26. a. Aldosterone.
27. b. To determine if the DM patient has been maintaining adequate blood
glucose level for the previous 120 days.
28. a. To assess patients’ ability to see distances when they are unable to read.
29. c. Dual-energy X-ray absorptiometry.
30. d. All of the above.
31. a. A sedative may invalidate the test results because it might slow down
respiration.
32. d. All of the above.
33. a. To assess the speed, direction, and fl ow of blood.
34. b. Some antibiotics contain potassium.
35. d. All of the above.
36. a. Skin patch test.
37. a. The patient is at high risk for breast cancer and the MRI provides high,
detailed views of the patient’s breasts.
38. d. All of the above.
39. a. Creatinine clearance test.
40. a. The patient might have diffi culty excreting the contrast material.
41. d. All of the above.
42. d. All of the above.
Medical Tests and Procedures Demystifi ed 609
43. a. This test identifi es heterophil antibodies that form between 2 and 9
weeks after the patient becomes infected.
44. c. Total hysterectomy with bilateral salpingo-oophorectomy.
45. b. Tracer material helps map the route through which cancer cells spread
from the cancer site through the lymphatic system.
46. c. Volume and capacity of the lungs.
47. a. Allen test.
48. d. All of the above.
49. b. To generate an image of the heart that is not obstructed by bone.
50. c. Bacterial vaginosis.
51. a. Depend on the patient’s age, height, sex, weight, and race.
52. a. The entire skin lesion is removed.
53. d. All of the above.
54. b. Will not show symptoms of carbon monoxide poisoning.
55. a. The upper segment of the vagina collapses and extends outside the vagina.
56. c. This causes the thyroid gland to be pushed forward.
57. b. Metabolic alkalosis.
58. a. A radioactive tracer being injected into a blood vessel.
59. b. A needle is inserted through the urethra to remove samples of prostate
tissue.
60. c. Tenaculum clamp.
61. c. Metabolic acidosis.
62. b. Lung scan.
63. c. Identifi es the anti-cardiolipin antibodies.
64. a. Carbon monoxide test.
65. a. An ambulatory electrocardiogram.
66. a. A procedure performed to assess for testicular cancer.
67. c. Breast lift.
68. a. Measures the ejection fraction of the heart.
69. b. If there is a suspicious result on a mammogram.
70. c. Determines the presence of H pylori in the stomach.
71. b. The tracer is likely to pass to the baby in breast milk.
610 Nursing Lab and Diagnostic Tests Demystifi ed
72. c. The number of particles of substances that are dissolved in the serum.
73. a. A sputum cytology studies cells contained in the sputum and a sputum
culture identifi es microorganism in the sputum.
74. a. To assess the velocity and direction of blood fl owing through the penis.
75. a. Does not have to have a full bladder for the test.
76. c. Fetal blood cells are being attacked by the mother’s antibodies.
77. a. To screen for anemia.
78. a. The patient has arthritis.
79. a. To measure the eardrum’s response to pressure and sound.
80. d. All of the above.
81. a. Pilocarpine helps to draw sweat from the newborn.
82. c. Sterile water is inserted into the bladder using a urinary catheter.
83. c. A score that compares the patient’s bone mineral density with that of
people his/her own age, sex, and race.
84. b. Fructose provides energy to sperm.
85. b. To screen for uric acid kidney stones.
86. d. Otoacoustic emissions test.
87. a. The time necessary for semen to liquefy.
88. d. All of the above.
89. c. To induce contractions.
90. b. Have a full bladder before the test.
91. a. Sonogram.
92. b. Speech reception/Word recognition.
93. a. Highlights growths found during a testicle examination.
94. a. The fontanelles are closed.
95. d. All of the above.
96. d. All of the above.
97. b. Notify the healthcare provider.
98. d. Assess the patient’s overall health.
99. b. The snap gauge consisting of a fi lm is placed around the penis. The fi lm
snaps when the patient has erection.
100. a. Higher risk of infection following surgery
Identifying Data A. Includes patient’s thoughts and feelings about the illness
Reliability B. Risk factors
Chief Complaint(s) C. May include a genogram
Present Illness D. Establishes source of referral
Past History E. Documents personal/social history and daily living routines
Family History F. One or more major symptoms or concerns
Review of Systems G. Systemic documentation of presence or absence of common
symptoms
Health Patterns H. Varies according to the patient’s memory, trust, and mood
The type of data that can be described only by the person experiencing it is
[subjective;objective;summative]