EXAM 2 HEALTH ASSESSMENT STUDY QUESTIONS
CHAPTER 1
MULTIPLE CHOICE
1.After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be :
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:A
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data.
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 2
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
2.A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data
would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:C
Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data.
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 2
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
3.The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. ANS:A
Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patient’s record, laboratory studies, or data.
DIF:Cognitive Level: Remembering (Knowledge) REF:p. 2
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
8.The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
ANS:D
First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 4
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
9.When considering priority setting of problems, the nurse keeps in mind that second-level priority
problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
ANS:C
Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1).
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 4
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
10.Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data d. Distinguishing relevant from irrelevant
ANS:B
Clustering related cues helps the nurse see relationships among the data.
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 2
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
11.The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
ANS:A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions.
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 6
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
12.The nursing process is a sequential method of problem solving that nurses use and includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
ANS:D
The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 3
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
18.When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient’s health state.
d. Holistic health views the mind, body, and spirit as interdependent.
ANS:D
Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state.
DIF:Cognitive Level: Understanding (Comprehension) REF:p. 7
MSC:Client Needs: Safe and Effective Care Environment: Management of Care
CHAPTER 5
MULTIPLE CHOICE
1.During an examination, the nurse can assess mental status by which activity?
a. Examining the patient’s electroencephalogram
b. Observing the patient as he or she performs an intelligence quotient (IQ) test
c. Observing the patient and inferring health or dysfunction
d. Examining the patient’s response to a specific set of questions
ANS:C
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects.
PTS:1DIF:Cognitive Level: Understanding (Comprehension)
REF:p. 67MSC:Client Needs: Psychosocial Integrity
2.The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
a. All aspects of mental status in children are interdependent.
b. Children are highly labile and unstable until the age of 2 years.
c. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years.
d. A child’s mental status is impossible to assess until the child develops the ability to concentrate.
ANS:A
Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true.
PTS:1DIF:Cognitive Level: Understanding (Comprehension)
REF:p. 68MSC:Client Needs: Psychosocial Integrity
3.The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:
a. Will have no decrease in any of his abilities, including response time.
b. Will have difficulty on tests of remote memory because this ability typically decreases with age.
c. May take a little longer to respond, but his
general knowledge and abilities should not
have declined.
d. Will exhibit had a decrease in his response
time because of the loss of language and a decrease in general knowledge.
ANS:C
The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:p. 68MSC:Client Needs: Psychosocial Integrity 4.When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities
ANS:D
Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, and social isolation and makes the person appear confused.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:p. 68MSC:Client Needs: Psychosocial Integrity
5.The nurse is preparing to conduct a mental status examination. Which statement is true regarding
the mental status examination?
a. A patient’s family is the best resource for information about the patient’s coping skills.
b. Gathering mental status information during the health history interview is usually sufficient.
c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time.
d. To get a good idea of the patient’s level of
functioning, performing a complete mental status examination is usually necessary.
ANS:B
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:p. 68MSC:Client Needs: Psychosocial Integrity
6.A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action?
a. Perform a complete mental status examination.
b. Refer him to a psychometrician.
c. Plan to integrate the mental status examination into the history and physical examination.
d. Reassure his wife that memory loss after a
physical shock is normal and will soon subside.
ANS:A
Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:p. 69MSC:Client Needs: Psychosocial Integrity
7.The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
a. “I sleep like a baby.”
b. “I have no health problems.”
c. “I never did too good in school.”
d. “I am not currently taking any medications.”
ANS:C
In every mental status examination, the following factors from the health history that could affect
the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient’s normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:p. 69MSC:Client Needs: Psychosocial Integrity
8.A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse’s best approach regarding this examination is to:
a. Plan to defer the rest of the mental status examination.
b. Skip the language portion of the
