Nursing Assessment Exam 1 2025
____ is main source of fatty acids and is essential for normal growth and development. - ansFat.
_____ artery is most frequently used to measure heart rate because accessible and easily palpated. - ansRadial
_____ is used to gather more information. - ansClarif...
Nursing Assessment Exam 1 2025
____ is main source of fatty acids and is essential for normal growth and development. - ansFat.
_____ artery is most frequently used to measure heart rate because accessible and easily palpated. -
ansRadial
_____ is used to gather more information. - ansClarification.
_____ reflection is repeating what the patient said and encourages elaboration or more information. -
ansReflection
______ is used when inconsistencies are noted between patient report and nurse's observations. -
ansConfrontation
_______ condenses and orders data to clarify sequence of events for that pt. It emphasizes data
related to health promotion, disease protection, and resolving health problems - ansSummary
_______ is repeating what patient says ini different words to confirm interpretation. -
ansRestatement
_______ is used to share conclusions drawn from data. Pt. may then confirm, deny, or revise -
ansInterpretations
_______ uses verbal and nonverbal phrases to encrourage patinets to continue to talk further. -
ansFacilitation
A mother of three is being seen for a screening assessment. While planning the initial part of the visit
with this patient, the nurse needs to ensure that:
,a)The patient receives a refill for her thyroid medication.
b)The patient is instructed on preventive measures for hypertension.
C)Other family members are present during the interview.
D)Information about the patient's lifestyle habits is gathered. - ansCorrect Answer: D
Rationale: There are multiple types of health assessments. If a patient receives a refill, this is an
episodic or follow-up assessment. If a patient is instructed in preventive measures, this is more along
the lines of a comprehensive assessment. A screening assessment would require the nurse to have
data about lifestyle habits.
A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her
toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the
curvature of the spine is an example of:
A)Health education
B)Primary prevention
C)Secondary prevention
D)Tertiary prevention - ansCorrect Answer: C
Rationale: Primary prevention is preventing the disease before it begins. Secondary prevention means
that the nurse is trying to detect disease as early as possible to improve outcomes.
A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need to assess her
blood pressure. The nurse explains to the patient that:
A) Using a cuff that is too narrow will give a reading that is inaccurate and high.
B) Deflating the cuff too quickly will make the reading inaccurate and high.
C) Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high.
D) Waiting 3 minutes before repeating the blood pressure measurement will result in a false-high
,blood pressure measurement. - ansCorrect Answer: A
Rationale: Cuff width should be 40% of the circumference of the limb to be used to assess blood
pressure. Quick deflation (faster than 2 mm Hg to 3 mm Hg per second) makes the blood pressure
measurement inaccurate and low. Waiting 3 minutes between repeat blood pressure measurements
will help ensure an accurate second reading.
After completing a dressing change and tidying up the room, the nurse asks the patient if she needs
anything. The patient responds, "I am just tired of being tired. Ever since my husband died, I can't
seem to sleep more than 3 to 4 hours a night. I can't find anything fun to do, and all my friends seem
to have disappeared." The nurse discloses this information to the social worker and recommends that
the patient:
A) Start taking diphenhydramine at bedtime.
B) Be assessed on the Beck short form.
C) Undergo AUDIT assessment.
D) Undergo CAGE assessment. - ansCorrect Answer: B
Rationale: The Beck short form is used to screen for depression. The nurse could talk with a nurse
practitioner or physician about a sleep aid, but further assessment is needed. The AUDIT and CAGE
tests are used to assess for alcohol use.
Assessment of circulation, motion, and sensation is done every 8 hours in a patient recovering from a
laminectomy 3 days after surgery. The patient had the surgery for consistent low back pain. Now on
day 3, the patient has a burning sensation on the lateral edge of the right foot. This is best described
as:
A) Cellulitis.
B) Nociceptive pain.
C) Fasciitis.
D) Neuropathic pain. - ansCorrect Answer: D
Rationale: Cellulitis is an interstitial infection. Nociceptive pain is usually associated with tissue
, destruction or damage. Neuropathy is connected to nerve-related pain. It would appear that a nerve
is being disturbed as a result of the surgery or the initial disease process. Burning sensation is a classic
presentation or complaint related to nerve pain.
Because a nurse seeks to create a patient-centered interview process, the nurse will:
A) Ask the patient, "Do you suffer from any arthralgias?"
B) Give the patient as little information as possible to avoid fear.
C)Ask the patient, "Can you please tell me more about your spells?"
D) Inform the patient, "You don't have to share anything with me that makes you uncomfortable." -
ansCorrect Answer: C
Rationale: The word "arthralgia" may be a word that many patients do not understand. The nurse
needs to be careful when withholding information related to not wanting to "scare" the patient. It is
best if the nurse works with the patient on identifying what information the patient wants to receive.
There could be an age-appropriate component to this (i.e., children), in which case the nurse will work
with caregivers to ensure that all required information is given. In option "C," the patient has used the
word "spells." The nurse should not discourage this but should investigate further. In option "D," the
nurse should not say this; often there is sensitive material that must be covered or addressed to
provide adequate care.
Begin interviews with what type of questions? - ansopen-ended. encourage a free-flowing open
response.
Body temperature is regulated by the ______. Expected temperature ranges from 96.4 to 99.1. -
ansHypothalamus
Causes of hyperlipidemia? - ansdietary fat and genetics.
Clinical findings of hyperlipidemia? - ansHyperlipidemia is not associated with clinical symptoms until
cardiovascular event occurs.
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