,1. A nurse is conducting a health history interview with a 65-
year-old male patient who complains of chest pain. Which of
the following questions is most appropriate to ask first?
a) Do you have any history of heart disease or hypertension?
b) How would you rate your pain on a scale of 0 to 10?
c) When did the pain start and what were you doing at that
time?
d) What does the pain feel like and where is it located? *
Rationale: The most appropriate question to ask first is the one
that assesses the quality and location of the pain, as this can
help determine the possible cause and severity of the chest
pain. The other questions are also important, but they can be
asked later.
2. A nurse is performing a physical examination on a 25-year-
old female patient who is pregnant for the first time. Which of
the following findings is normal during pregnancy?
a) Increased blood pressure
b) Decreased respiratory rate
c) Increased heart rate *
d) Decreased urinary output
Rationale: The normal physiological changes during pregnancy
include an increase in heart rate, cardiac output, blood volume,
and respiratory rate. Blood pressure usually remains stable or
slightly decreases in the first trimester, then increases
gradually in the second and third trimesters. Urinary output
also increases due to increased renal blood flow and
glomerular filtration rate.
3. A nurse is assessing the cranial nerves of a 45-year-old male
, patient who has a history of stroke. Which of the following
tests is used to assess the function of cranial nerve VII (facial
nerve)?
a) Ask the patient to smile, frown, raise eyebrows, and puff out
cheeks *
b) Ask the patient to identify different smells with each nostril
c) Ask the patient to read a Snellen chart and test peripheral
vision
d) Ask the patient to clench teeth, move jaw side to side, and
open mouth against resistance
Rationale: The facial nerve innervates the muscles of facial
expression, so asking the patient to perform various facial
movements can test its function. The other tests are used to
assess other cranial nerves, such as olfactory (I), optic (II), and
trigeminal (V).
4. A nurse is evaluating the nutritional status of a 35-year-old
female patient who has a body mass index (BMI) of 18.5
kg/m2. Which of the following statements is true regarding this
patient's BMI?
a) It indicates that the patient is overweight
b) It indicates that the patient is underweight *
c) It indicates that the patient is obese
d) It indicates that the patient has a normal weight
Rationale: BMI is a measure of body fat based on height and
weight. A BMI of 18.5 kg/m2 or less indicates that the patient is
underweight, which may increase the risk of malnutrition,
infection, and osteoporosis. A BMI of 25 kg/m2 or more
indicates that the patient is overweight or obese, which may
increase the risk of cardiovascular disease, diabetes, and some
cancers. A BMI of 18.5 to 24.9 kg/m2 indicates that the patient
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