Study Questions:

COMMUNICATION
● What communication strategies should a nurse implement when establishing a
therapeutic relationship with a 75 year old nursing home resident?
○ Listening attentively is therapeutic and reminisce increases self worth in
the elderly population.
■ The nurse should communicate with the patient and speak in a
normal voice. The nurse should use open ended questions.
● A patient is paralyzed due to injuries sustained in a car accident. The patient
states “I wish I would have just died.”
○ Tell me more about your concerns and feelings.
■ You want to encourage the patient to verbalize fears and concerns.
● A nurse administered medication to a patient to reduce nausea. What question
should the nurse ask to evaluate the effectiveness of the medication?
○ How is your nausea now?
■ The patient's answer to this direct close ended question will give a
direct answer to the effectiveness of the medication.
● What should a nurse do to establish a therapeutic relationship with a patient?
○ Ensure verbal and nonverbal communication are congruent.
■ Patients will believe nonverbal signs more than verbal if they are
incongruent. This will have a negative impact on the therapeutic
relationship.
● A patient apologizes to a nurse for not being able to self administer an insulin
injection. How should the nurse respond?
○ Tell me what keeps you from self administering your own insulin
injections?
 ■ The nurse should assess if the patient has a knowledge deficit
regarding administering self injections and teach the patient the
correct method.
● The nurse is receiving a handoff report for a newly admitted patient. What
information should be contained in this form of communication?
○ Transfer of responsibility and accountability, clarity of information,
verbal communication of information.
■ Handoff report consists of a transfer of responsibility and
accountability, clarity of information, verbal communication of
information, acknowledgement by reviewer, and opportunity to
review.
● A confused patient is wearing thick glasses and a hearing aid. Place an order the
steps taken by the nurse to facilitate communication.
○ First, the nurse needs to assess for impairments to communication
before beginning caring for the patient.
○ Second, setting goals and outcomes would be the next step for the patient
and the nurse to agree upon.
○ Third, utilizing therapeutic communications interventions allows the
patient to assist the nurse in implementing the plan of care.
○ Last, the nurse would evaluate the goals and outcomes to ensure that
they were met.
● A nurse is inspecting the nutritional status of a patient who has lost 10 lbs over
the past month. What question should the nurse ask to obtain more
information?
○ What factors have contributed to your weight loss over the last couple of
months?
 ■ An appropriate way to gain access to information is an
open-ended non judgemental question.

ASSESSMENT
● How should a nurse document this patient finding?
○ Edema 1+
■ An assessment finding where an indentation of 2 cm is indicative
of edema +1.
■ The absence of edema is a normal finding. Generalized edema
does not leave an indentation.
■ Pitting edema of 2+ would be an indentation of 4 cm.
● The nurse is conducting a physical assessment of the abdomen. Which position
is preferred for this patient?
○ Dorsal recumbent
■ Dorsal recumbent (flat) position causes the abdominal muscles to
relax and is the preferred position for assessment of the abdomen.
■ Supine and sitting may be used, but dorsal recumbent is the
preferred position. Prone (flat on stomach) and sims (side) would
not give access to the abdomen.
● A patient states to a nurse, “I am allergic to penicillin.” Which assessment
questions are best to learn more about the patient's allergies?
○ What type of reaction occurred?
■ The nurse should ask the patient to expand about the type of
reaction that occurred when penicillin was administered.
● A nurse is auscultating a patient's blood pressure. The first sound heard is at
136 mmHg, then a thumping sound continuing down to 122 mmHg, then soft
thumping sounds continuing down to 96 mmHg, then muffled sounds
 continuing down to 82 mmHg, then silence. How should the nurse interpret this
blood pressure?
○ Hypertensive Stage I
■ Hypertensive stage I is categorized as systolic 130-139 and diastolic
80-89.
● A nurse identifies arcus senilis while performing a health assessment on a 75
year old patient. What is the appropriate nursing action?
○ Document the findings.
■ Arcus senilis in a 75 year old patient is a normal finding. It is not
caused by or treated with medication.
● A nurse auscultates adventitious sounds when assessing the breast sounds of a
patient. What should be the next action of the nurse?
○ Ask the patient to cough, then reassess.
■ Coughing may clear the airway. Adventitious sounds in an
otherwise stable patient does not warrant immediate reporting.
● A nurse is assessing the carotid arteries of a patient. What is an appropriate
nursing action?
○ Locate and palpate the carotid artery in the lower 3rd of the neck.
■ The proper procedure for palpating the carotid artery is to palpate
one side in the lower half of the neck. The lower half of the neck is
used to prevent stimulating the vagus nerve in the upper part of
the neck.
● While obtaining a health history, a nurse would ask the patient their reason for
seeking healthcare. What information is the nurse collecting?
○ Chief complaint
 ■ Chief complaint is the medical term used to describe the primary
problem of the patient which led the patient to seek medical
attention.
● A nurse is assessing a patient. Which finding requires immediate action?
○ Clear drainage from the ear.
■ Any clear discharge should be reported as this may be cerebral
spinal fluid.
● A nurse is assessing the vital signs of a patient who is 5’11 and weighs 390 lbs.
The nursing histories show that the patient is compliant with antihypertensive
medications at home and the patient's hypertension is under control. Today the
patient's BP is 152/98. What is the appropriate nursing action?
○ Reassess the BP with a larger cuff.
■ Equipment size is important for accurate measurement of blood
pressure.
● A nurse is caring for a patient with a temperature of 102.2. Which nursing
actions would be appropriate for this patient?
○ Remove heavy covers.
■ Removing covers will assist with hypothermia by radiation.
● An elderly Spanish speaking patient makes an appointment for a routine annual
assessment with a new primary care provider. Which action by a nurse is
appropriate when conducting the health history?
○ Have a medical translator available during the health history.
■ A patient who is Spanish speaking will require a translator to be
available during the health history portion of the assessment. If
family is used for a translator, it needs to be documented.
● A nurse is assessing a patient for orthostatic hypotension. What is an
appropriate nursing action to determine if the patient is experiencing
orthostatic hypotension?
○ Assess the BP in a supine position and have the patient sit up and
reassess.
■ Orthostatic hypotension is a blood pressure reading that decreases
when the patient sits or stands. You must remeasure the blood
pressure when the patient changes position.
● A nurse documents PERRLA after examination of a patient's eyes. What action
by the nurse assesses the letter A in the acronym PERRLA?
○ Assess if the pupil constricts when asked to focus on a near object.
■ The A in PERRLA stands for accommodation and refers to the
ability of the pupil to constrict when focusing on a near object.
● A nurse enters a room to assess vital signs of a patient who is experiencing
eupnea. The patient is on the telephone. What is the most appropriate action of
the nurse to take?
○ Defer measurement of the respirations to a later time.
■ Eupnea is normal respirations. The patient is not in distress so the
measurement can be deferred.
● A nurse is assessing an older adult patient during a routine health maintenance
visit. To assess the patient's range of motion of the knees, which action by the
nurse is appropriate?
○ Seek the patient, extend the knee, and instruct the patient to alert the
nurse of any pain.
■ To assess the range of motion of the knees, the patient should be
placed in the sitting position. The nurse will instruct the patient to
alert the nurse at the first sign of discomfort while checking the
 range of motion of the knees. Seating the patient is appropriate,
but the knee is not forced beyond the pain limit.
● A patient presents with a temperature of 102, complains of nausea, has
experienced vomiting and diarrhea for 12 hours, and has pale dry mucous
membranes. Which nursing assessment is the most appropriate?
○ Assess skin turgor.
■ A patient who presents with fever, vomiting, diarrhea, and pale dry
mucous membranes requires assessment for dehydration.
Assessment for turgor will provide more information for the
patient's hydration status.
● A nurse assesses a patient using palpation. What information will the nurse be
able to gather using this assessment technique?
○ Peripheral pulses, landmarks to locate the point of maximum impulse,
capillary refill, peripheral edema
● A nurse receives a report on 4 patients. Which patient should the nurse assess
first?
○ The first patient you would assess is the 50 year old man with a stroke.
Temperature: 98.6, pulse: 106, respirations: 12, and BP: 88/58.
■ An elevated pulse with a decreased BP is cause for concern and
should be given priority assessment versus other patients with
normal vital signs.
● A nurse is collecting information to complete a nursing health history. What is
the best source of data?
○ The patient.
■ The reason the patient is the primary source of data is because
family and medical providers are secondary.
● A nurse is preparing to complete a physical exam on a patient. The nurse shows
a knowledge deficit when including which nursing intervention?
○ When she includes family members.
■ Visitors of family members should be asked to leave to provide for
patient privacy unless the patient asks them to stay.