A patient tells the nurse that he is very nervous, that he is nauseated, and that he
"feels hot." This type of data would be:
a.) Objective
b.) Reflective
c.) Subjective
d.) Introspective - ANSWER-C
When considering priority setting of problems, the nurse keeps in mind that
second-level priority problems include which of these aspects?
a.) Abnormal laboratory values
b.) Low self-esteem
c.) Lack of knowledge
d.) Severely abnormal vital signs - ANSWER-A
When reviewing the use of alcohol by older adults, the nurse notes that older
adults have several characteristics that can increase the risk of alcohol use.
Which would increase the bioavailability of alcohol in the blood for longer periods
of time in the older adult?
a.) Decreased blood pressure
b.) Increased muscle mass
c.) Increased cardiac output
d.) Decreased liver and kidney functioning - ANSWER-D
The nurse is aware that intimate partner violence (IPV) screening should occur
with which situation?
a.) When IPV is suspected
b.) As a routine part of each health care encounter
c.) When a woman has an unexplained injury
, d.) When there is a known history of abuse in the family - ANSWER-B
The nurse is assessing bruising on an injured patient. Which color indicates a
new bruise that is less than 2 hours old?
a.) Purple-blue
b.) Brownish-yellow
c.) Greenish-brown
d.) Red - ANSWER-D
The nurse suspects abuse when a 10-year-old child is taken to the urgent care
center for a leg injury. The best way to document the history and physical
findings is to:
a.) use the words the child has given to describe how the injury occurred
b.) write what the child's caregiver tells the nurse
c.) write what the nurse observes during the conversation
d.) rely on photographs of the injuries - ANSWER-A
As a mandatory reporter of child abuse, which of these must be present before a
nurse notifies the authorities?
a.) Verification from the victim
b.) Proof of abuse and/or neglect
c.) Statements from witnesses
d.) Suspicion of child abuse and/or neglect - ANSWER-D
During a nutritional assessment of a 22-year-old male refugee, the nurse must
remember to:
a.) obtain a 24-hour dietary recall
b.) clarify what is meant by the term "food."
c.) provide him with a standard dietary handbook
d.) assume that his diet is consistent with other refugees from the same country -
ANSWER-B
The nurse needs to perform anthropometric measures of an 80-year-old man who
is confined to a wheelchair. Which of the following is true in this situation?
a.) Changes in fat distribution will affect the waist-to-hip ratio
b.) Height measurements may not be accurate because of changes in bone
c.) Declining muscle mass will affect the triceps skinfold measure
d.) Mid-arm circumference is difficult to obtain because of loss of skin elasticity -
ANSWER-B
Monitoring a patient's waist-to-hip ratio provides data concerning:
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