Health Assessment In Nursing 6th By Janet R. Weber – Test Bank
1. A nurse is completing the intake assessment of an older adult who has just relocated to a
long-term care facility. Which of the following nursing actions would be most important
to ensure accurate data when gathering the resident’s information?
A) Documenting the data
B) Validating the data
C) Identifying client support systems
D) Determining client needs
2. A nurse is assessing a female client whose worsening sciatica has prompted her to seek
care. Which of the client’s following statements would the nurse most likely need to
A) ìI don’t generally have problems with pain.î
B) ìI feel very weak and tired right now.î
C) ìI’ve had two cesarean deliveries.î
D) ìMy mother died of breast cancer in her sixties.î
3. A client who had a mastectomy is being discharged home on postoperative day 1.
Knowing that the client lives alone, which data would be most important for the nurse to
validate for this client?
A) If the client has transportation for follow-up appointments
B) If the client usually functions independently
C) What support systems are in place to assist the client
D) If the client has a religious belief regarding illness
4. When describing the importance of documenting initial assessment data to a group of
new nurses, which of the following would the nurse emphasize as the primary reason?
A) Health care institutions have established policies regarding documentation.
B) Incorrect conclusions may be made without documentation of the nurse’s opinions.
C) It satisfies legal standards established by health care organizations and institutions.
D) It becomes the foundation for the entire nursing process.
5. A nurse has documented the nursing history and physical examination of a client. This
health information is best described as which of the following?
A) Subjective data and objective data
B) Interpretation and inference
C) Observation and inspection
D) Data and results
6. The nurse is caring for a client with influenza symptoms and is documenting the initial
and ongoing assessment database. Which of the following would the nurse emphasize as
the major rationale for this action?
A) Reducing the fragmentation of care
B) Maximizing the efficiency of care
C) Promoting communication between disciplines
D) Facilitating achievement of professional standards
7. A nurse has completed a client’s initial assessment and is now interpreting and making
inferences from the data. The nurse is involved in which phase of the nursing process?
8. A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal
findings on her recent mammogram. Which of the following statements best reflects
appropriate documentation by the nurse?
A) ìClient depressed because of fear of breast biopsyî
B) ìClient with lower back painî
C) ìClient has unkempt appearance and avoids eye contactî
D) ìClient has good lung sounds in right and left lungsî
9. A nurse is working in a health care facility that uses charting by exception. Which of the
following would the nurse expect to document?
A) Liver palpation normal
B) No tenderness on palpation
C) Bowel sounds normoactive
D) Decreased range of motion in right shoulder
10. A task force has been established at a hospital with the aim of overhauling the
assessment forms that are used throughout the facility. Which of the following options is
most likely to help standardize the process of data collection?
A) Open-ended form
B) Integrated cued checklist form
C) Cued or checklist form
D) Nursing minimum data set
11. A nurse is providing in-service training to a group of nurses in a facility that has just
begun to use an integrated cued checklist for documentation. Which of the following
would the nurse identify as a major advantage of this type of documentation?
A) It helps nurses to cluster assessment data.
B) It provides lines for the nurses’ comments.
C) It includes specialized data particular to each client.
D) It standardizes data collection.
12. A group of nursing students is reviewing the purposes of assessment documentation in
preparation for a class discussion. The students demonstrate understanding of the
information when they identify which of the following as one of the primary purposes?
A) It provides a chronologic source of client assessment data.
B) It creates a database for care that was not rendered to the client.
C) It replaces the client acuity classification system.
D) It directly formulates the nursing diagnoses.
13. A nurse is comparing the subjective data and objective data obtained from an
assessment of a client who is thought to have hepatitis A. This nurse’s comparison will
achieve what benefit to this client’s care?
A) Formulation of nursing diagnoses
B) Identification of missing data
C) Determination of documentation form to use
D) Validation of data
14. A nurse is preparing an in-service education program for a group of staff nurses about
documentation, including documentation of assessment data. The nurse demonstrates
understanding of the significance of documentation by including a discussion of which
of the following as playing a role in this area? Select all that apply.
A) Joint Commission
B) State nurse practice act
D) Local or city government
E) Institutional agency
15. A nurse has completed an assessment of a client with cholecystitis and is about to
document the findings. Which statement best reflects accurate documentation?
A) Client appears upset about upcoming surgery.
B) Client was interviewed about previous history of hypertension.
C) Skin pale, warm, and dry without evidence of lesions.
D) Client’s oral intake is satisfactory.
16. A nurse is using a nursing minimum data set to document findings following the
assessment of a client. This nurse is most likely providing care in which setting?
A) Acute care facility
B) Long-term care facility
C) Urgent care center
D) Health clinic
17. While performing the initial assessment of a client, the client tells the nurse that this is
his first hospitalization and that he has no previous surgeries. The nurse should
document which of the following?
A) Client denies prior hospitalizations and surgeries
B) Client has not been hospitalized before nor has he had any surgery
C) Client answered no to previous hospitalizations or surgery
D) Negative for past hospitalizations
18. An instructor is describing various ways that a nurse can validate data to a group of
nursing students. The instructor determines that additional teaching is necessary when
the students identify which of the following as a reliable method?
A) Repeating the assessment
B) Asking additional questions
C) Having the client repeat what was said
D) Checking findings with another health care professional
19. A nurse is working on an acute neurological unit. Which assessment form would the
nurse most likely use to document assessment data?
A) Open-ended form
B) Focused assessment form
C) Frequent assessment form
D) Ongoing assessment form
20. A group of students is reviewing information from class about the purposes of
assessment documentation. The students demonstrate understanding of the material
when they state which of the following?
A) ìDocumentation helps support reimbursement but gives little epidemiologic data.î
B) ìDocumentation provides a permanent legal record of care given and not given.î
C) ìDocumentation is a viable means of communication but is repetitious.î
D) ìDocumentation helps determine client education needs but not staff mix.î
21. A nurse is providing a verbal update to a client’s primary care provider because of the
client’s worsening nausea. When using an SBAR format to provide a report, the nurse
should complete the report with which of the following statements?
A) ìWhat would you like to do to address this client’s nausea?î
B) ìI think this client would benefit from an antiemetic.î
C) ìThis client has no recent history of any nausea or vomiting.î
D) ìThis client rates his nausea as seven out of ten.î
22. A surgical client’s pain has become increasingly severe overnight, and she has received
her maximum current doses of analgesics. The nurse has consequently phoned the
surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new
order, how should the nurse best validate this information?
A) Read the order back to the surgeon for confirmation.
B) Compare the order with the standard timing and dosage of the analgesic.
C) Compare the order to the client’s existing medication administration record (MAR).
D) Have another nurse read the order that the nurse has transcribed.
23. An audit of a hospital unit’s incident reports reveals that several errors have resulted
from incomplete or inaccurate information during change-of-shift handoff. In order to
prevent such errors, what practice should be encouraged on the unit?
A) Delegate handoff reports to unlicensed care providers who have fewer demands on
B) Use an intermediary to receive report from the first nurse and then provide the
handoff report to the second nurse.
C) Involve as few people as possible in the verbal report.
D) Encourage nurses to perform handoff as quickly as possible.
24. A client has illuminated his call light and tells the nurse that he is having ìten out of tenî
pain. The nurse’s initial inspection reveals that the client is watching videos on his tablet
computer and appears to be at ease physically and emotionally. How should the nurse
validate the client’s subjective complaint of pain?
A) Ask the client to repeat his rating of his pain.
B) Observe the client for several seconds to see if his demeanor or his behavior
C) Consult the client’s medication administration record (MAR) to check for recent
D) Perform further assessments addressing various aspects of the client’s pain.
25. A hospital nurse is admitting a client with a documented history of acute pancreatitis,
liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding
would most clearly warrant validation?
A) The client’s blood pressure is 148/88 mm Hg.
B) The client is oriented to person and place but not to time.
C) The client states that she only drinks alcohol on a social basis.
D) The client states, ìMy skin’s kind of yellow because of my liver.î
26. A small, rural hospital is revising the policies and procedures surrounding
documentation in an effort to align practices with the Health Information Technology
for Economic and Clinical Health (HITECH) Act. How can the requirements of this
legislation best be met?
A) Expand the use of the Nursing Minimum Data Set.
B) Eliminate the use of verbal handoffs between nurses.
C) Increase interdisciplinary collaboration in the hospital.
D) Increase the use of electronic health records (EHRs) in the hospital.
27. The nurse is reviewing and analyzing data from the initial assessment of a newly
admitted client who is a 79-year-old man. What assessment finding most clearly
indicates a need for further data?
A) The man has male pattern baldness.
B) The man has a diffuse rash on his torso.
C) The man’s heart rate is 63 beats per minute.
D) The man had an inguinal hernia repair in 2008.
28. There has been some resistance to the planned transition to electronic health records
(EHRs) in a hospital system, with many caregivers questioning the rationale for this
change in practice. What potential advantage of EHRs should administrators cite?
A) Increased influence for the nursing profession
B) Elimination of documentation
C) Improved continuity of care
D) Reduced nursing workload
29. While assisting an older adult with morning hygiene, the nurse notes a lesion on the
client’s coccyx region. How should the nurse best document this objective assessment
A) ìPossible pressure ulcer observed over client’s coccyx region.î
B) ìReddened area noted on skin surface superficial to client’s coccyx.î
C) ìArea of nonblanching erythema noted over client’s coccyx, 2 cm ◊ 2 cm.î
D) ìImpaired Skin Integrity related to decreased mobility.î
30. A nurse is conscientious in adhering to the requirements of the Health Insurance
Portability and Accountability Act (HIPAA) when providing care for clients. What
action best meets these legal requirements for care?
A) Having a colleague audit the nurse’s documentation to ensure objectivity
B) Maintaining the privacy and confidentiality of clients’ medical records
C) Using electronic records whenever possible, rather than paper-based records
D) Collaborating with the client and his or her family prior to documenting
1. The nurse is preparing to assess the remote memory of a client who has a diagnosis of
early stage Alzheimer’s disease. Which question would be most appropriate for the
nurse to use?
A) ìCan you tell me what you have eaten in the last 24 hours?î
B) ìWhen did you get your first job?î
C) ìWhat did you do last evening?î
D) ìHow are an apple and orange the same?î
2. When assessing the mental status of a 67-year-old woman, the nurse detects some
difficulty with free-flow of thought and the woman’s ability to follow directions. Which
of the following would the nurse do first?
A) Use a Geriatric Depression Scale.
B) Refer for further medical evaluation.
C) Assess the client’s vision and hearing.
D) Refer the client to social services for home assistance.
3. The nurse utilizes the Depression Questionnaire on a client who has recently moved to a
long-term care facility. The total score is 22. Which of the following would be most
appropriate for the nurse to do next?
A) Refer for further evaluation.
B) Evaluate benefits versus risks of a mental health label.
C) Assess further for dementia.
D) Document this as a normal score.
4. The nurse notes that an older adult client is wearing multiple layers of clothing on a
warm fall day. Which of the following would be the nurse’s priority assessment at this
A) Asking whether the client often feels cold
B) Assessing the client’s developmental level
C) Reviewing the client’s culture for possible influence
D) Observing the client’s overall hygiene
5. A nurse is working in a clinic in a low-income neighborhood and assesses a female
adult client who states that she has a urinary tract infection. The nurse notes that the
client is unkempt, wearing stained clothing, and has a strong body odor. The client
mentions that she was evicted from her apartment two weeks ago. Which nursing
diagnosis would the nurse most likely identify for this client?
A) Caregiver role strain related to fatigue
B) Impaired skin integrity related to neurologic deficits
C) Deficient fluid volume related to possible urinary tract infection
D) Self-care deficit related to possible homelessness
6. When preparing to obtain information about a client’s mental and psychosocial status,
which of the following would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and behaviors.
B) Perform a neurologic examination to determine any deficits.
C) Check the client’s level of consciousness for changes.
D) Explain the purpose of the exam and types of questions.
7. A nursing student has been assigned to the care of a client whose history suggests the
need for a mental status assessment. This client most likely has a history of health
problems affecting what body system?
8. The nurse begins the physical examination of a newly admitted client by assessing the
client’s mental status. What is the nurse’s best rationale for performing the mental status
exam early in the assessment?
A) The client will be less anxious early, providing the nurse with more accurate and
B) The exam can provide clues about the validity of the client’s responses now and
C) The exam provides data about mental health problems that the client may be afraid
D) The client’s fears about having a serious illness may be alleviated by the results of
9. A client’s recent episode of becoming lost near his home has prompted the nurse to use
the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should
begin this assessment by asking what question?
A) ìHow would you respond if someone said that you might have dementia?î
B) ìCan I ask you some questions about your memory?î
C) ìDo you generally consider yourself to be an intelligent person?î
D) ìI want to ask you some questions to see if you have Alzheimer’s.î
10. Assessment of a client who has suffered a recent stroke reveals that he is unresponsive
to all stimuli and his eyes remain closed. The nurse documents the client’s level of
consciousness as which of the following?
11. An emergency department nurse has utilized the Confusion Assessment Method (CAM)
in the assessment of a 79-year-old client with a new onset of urinary incontinence. This
assessment tool will allow the nurse to confirm the presence of what health problem?
B) Vascular dementia
12. The nurse is assessing a client using the Glasgow Coma Scale following an acute
hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating
which of the following?
A) Deep coma
D) Alert and oriented
13. A woman brings her 69-year-old husband to the clinic for an evaluation because he has
become increasingly forgetful. Which of the following would lead the nurse to suspect
that the client has Alzheimer’s disease? Select all that apply.
A) ìHe repeats the same story, word for word, over and over again.î
B) ìHe took a fall when he was replacing a light bulb last month.î
C) ìI have to balance the checkbook now because he just won’t do it.î
D) ìIf I don’t tell him when to shower, he won’t and will fight me on it.î
E) ìHe got lost walking to the pharmacy around the corner the other day.î
14. As part of a mental status assessment, the nurse asks a client to draw the face of a clock.
This will allow the nurse to assess which of the following domains of mental status?
A) Concentration and orientation
B) Perceptions and thought processes
C) Visual perceptual and constructional ability
D) Expressions and feelings
15. A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders
Identification Test (AUDIT) as part of the standard admission protocol. After obtaining
a score of 9 from a recently admitted client, the nurse should recognize the possibility of
which of the following?
A) Hazardous and harmful alcohol use
B) Imminent liver disease
C) Acute pancreatitis
16. A nurse is assessing a client who is exhibiting decorticate posturing. Which of the
following would the nurse observe?
A) Extended upper extremities
B) Internally rotated lower extremities
C) Pronated forearms
D) Flexed hands at the side of the body
17. The nurse observes a client’s entire body posture to be somewhat stiff, with his
shoulders elevated upward toward the ears. The nurse would most likely interpret this to
indicate that the client is experiencing which of the following?
18. A nurse is reviewing a depression questionnaire completed by a client. Which of the
following would the nurse interpret as being suggestive of depression?
A) ìOccasionally I feel like my attention wanders.î
B) ìI haven’t noticed any change in my appetite.î
C) ìIt usually takes me over an hour to fall asleep.î
D) ìI might wake up once during the night but not often.î
19. A gerontologic nurse is assessing the speech of an older adult client. Which of the
following would the nurse characterize as an expected assessment finding?
B) Rapid speech
C) Moderate pace
D) Loud tone
20. A nurse asks a client the following question: ìWhat do you do if you have pain?î The
nurse is assessing which of the following aspects of cognitive function?
C) Abstract reasoning
21. A nurse is providing care for a client who has hepatic encephalopathy secondary to
chronic alcohol abuse. The nurse’s assessment reveals that the client often provides
incorrect answers to assessment questions. As well, the client makes statements that are
not grounded in reality. What nursing diagnosis is suggested by these assessment data?
A) Impaired Verbal Communication related to hepatic encephalopathy AMB
B) Acute Confusion related to hepatic encephalopathy
C) Ineffective Health Maintenance related to alcohol abuse AMB decreased cognition
D) Ineffective Coping related to alcohol abuse
22. A client has presented to the emergency department (ED) with a lower leg laceration
that she suffered ìwhile I was on a bender last night.î The nurse recognizes the need to
screen for alcohol use and will implement the CAGE questionnaire. What question will
the nurse ask during this assessment?
A) ìHave you ever experienced a memory blackout after drinking?î
B) ìHave you ever vomited blood after drinking alcohol?î
C) ìHave you ever been treated for alcohol abuse?î
D) ìHave you ever felt guilty about your alcohol use?î
23. A woman has accompanied her 80-year-old husband to a scheduled clinic visit and
expresses concern about subtle declines in his cognition. Which of the following
principles should guide the nurse’s assessment of the client’s mental status?
A) The nurse must modify the cognitive assessment to exclude assessments requiring
reading or writing.
B) The nurse should first explain to the couple that senility is expected among adults
over age 80.
C) The nurse must differentiate between age-related changes and the signs and
symptoms of dementia.
D) The nurse must explain that the results of the assessment will be used to determine
if admission to long-term care is necessary.
24. The intensive care nurse is working with a client who has increased intracranial pressure
secondary to a traumatic brain injury. The nurse is performing the hourly assessment of
the client’s level of consciousness and observes that the client’s eyes are closed. How
should the nurse first stimulate the client to assess for arousability?
A) Gently shake the client’s right shoulder and then his left shoulder.
B) Rub the client’s sternum with the knuckles.
C) Speak to the client clearly from a close distance.
D) Press down on one of the client’s nail beds.
25. A nurse is conducting a mental status assessment of a 70-year-old male client who is
being treated for depression. When assessing the client’s facial expression and eye
contact, the nurse should consider which of the following?
A) The nurse should inform the client that his facial expression is being assessed.
B) Reduced eye contact is an age-related physiological change.
C) Facial expression should be disregarded if the client has a diagnosed mental illness.
D) Eye contact is strongly influenced by cultural norms.
26. A 21-year-old woman has been admitted to the emergency department following an
accident that is suspected of being a suicide attempt. When assessing the client’s
perceptions, what question should the nurse ask the client?
A) ìHow would you describe your health these days?î
B) ìAre you able to smell and taste as well as you’ve been able to in the past?î
C) ìIf you found a stamped envelope on the street, what would you do?î
D) ìCan you tell me the circumstances surrounding your accident?î
27. A nurse in the emergency department is utilizing the SAD PERSONAS assessment
guide during the mental status assessment of a client. What is the most likely rationale
for the nurse’s choice of this assessment tool?
A) The client may have a high risk for suicide.
B) The client may have major depression.
C) The client may have schizophrenia or psychosis.
D) The client may be using alcohol excessively.
28. An 88-year-old woman has been admitted to the acute medical unit for the treatment of
a urinary tract infection that is thought to be progressing to urosepsis. When assessing
the client’s orientation, how should the nurse best gauge the client’s orientation to time?
A) ìCan you tell me approximately what time it is right now?î
B) ìAre you able to tell me today’s date?î
C) ìCan you tell me the date and the day of the week?î
29. During the mental status assessment of a new client, the nurse has asked the client to
describe some of the similarities and differences between a tennis ball and a soccer ball.
Despite adequate time and cuing, the client is unable to state any similarities or
differences. The nurse should document what assessment finding?
A) A deficit in practical intelligence
B) An inability to follow directions accurately
C) A deficit in abstract reasoning
D) A lack of spatial orientation
30. The nurse is assessing an older adult client’s mental status. Consistently, the client
pauses after the nurse poses a question, but then the client provides a response that is
correct or appropriate. How should the nurse best interpret this characteristic of the
A) Slight delays in mental processing are normal in older adults.
B) The client may be trying to anticipate the nurse’s desired response.
C) The client is displaying a sign of early Alzheimer’s disease.
D) The client may be experiencing an early sign of delirium.
1. The nurse is interviewing a female Hispanic client who is scheduled for a cardiovascular
education program. The client states, ìI can’t eat and I don’t sleep because my daughter
left to return to Mexico. I am sad and nervous. I need rest.î The nurse suspects that she
is suffering from susto. Which action by the nurse would be best?
A) Give her a multivitamin supplement.
B) Encourage her to exercise.
C) Reschedule the education program.
D) Refer her to a counselor.
2. A nurse is admitting a client who is from another culture. Prior to caring for a client
from another culture, the nurse should place primary importance on which action?
A) Examining personal biases and prejudices
B) Researching characteristics of the specific culture
C) Asking colleagues about ways to approach the client
D) Developing awareness of the culture’s health practices
3. A nurse educator is leading a group of nurses in exercises aimed at improving cultural
competence. Which of the following would the educator use to best describe an aspect
of the term ìcultureî?
A) Transmission occurs to another generation through genetics.
B) It is shared through norms for behaviors, values, and beliefs.
C) It is adapted to a specific environment.
D) It is experienced by all people even without human contact.
4. A nurse states, ìHispanic people have no clue about primary prevention of illness.î The
nurse is demonstrating which of the following?
C) Cultural incompetence
5. A nurse is assessing a client of East Asian descent. Which biological variation would
the nurse expect?
A) Dry cerumen in the client’s ears
B) Profuse perspiration in the client’s axillary area
C) Strong body odor
D) Longer eustachian tubes
6. A nurse who provides care in a busy, inner-city clinic performs physical examinations
on clients of various cultures. In a client from which group would the nurse expect to
find the greatest amount of body odor from perspiration?
D) Native American
7. An African-American woman collapses at the funeral of her mother and later states that
she could hear everything people were saying to her but, for a brief period, she could not
move. The nurse interprets this as which of the following?
B) Falling out
8. A nurse has identified the goal of becoming more culturally sensitive and competent.
What is the primary rationale for cultural sensitivity in health care settings?
A) Recognize that cultural diversity exists.
B) Understand individual differences.
C) Prevent offending the client.
D) Obtain accurate assessment data.
9. Based on a colleague’s feedback, a nurse learns that she is aware of cultural differences
in a general way but does not know what the specific differences are or how to
communicate with a person of a specific culture. This nurse exhibits which of the
A) Unconscious incompetence
B) Conscious incompetence
C) Conscious competence
D) Unconscious competence
10. A group of students is reviewing material on cultural competence. The students
demonstrate understanding of this concept when they identify which of the following as
the starting point?
A) Cultural awareness
B) Cultural desire
C) Cultural skill
D) Cultural knowledge
11. A male Hispanic client describes the fact that he mixed hot and cold foods, causing
them to lump together and ìget stuck in his intestines,î causing diarrhea and abdominal
pain. The nurse would document this as which of the following?
C) Mal ojo
D) Mal puesto
12. The nurse attends a Native-American Alcoholic Anonymous support group and
develops close relationships with three group members. The nurse is demonstrating
which of the following?
A) Cultural desire
B) Cultural awareness
C) Cultural encounter
D) Cultural knowledge
13. The nurse is preparing to lead a health promotion activity among a group of clients from
different cultures. The nurse would expect that which client would require the least
amount of personal space?
A) Latin American
D) Middle Easterner
14. A nurse is modifying an Asian client’s diet to accommodate the concept of hot and cold.
The nurse demonstrates an understanding of this concept when identifying which of the
following as a cold condition?
C) Sore throat
15. When reviewing cultural differences that relate to the incidence and prevalence of
disease among various cultural groups, the nurse would expect to see the highest
prevalence of asthma in which group?
A) Non-Hispanic blacks
C) African Americans
D) Southeast Asians
16. The nurse is assessing the diet and nutritional status of a client from a different culture.
Which of the following questions would be appropriate for the nurse to ask? Select all
A) ìWhat foods do you commonly eat?î
B) ìDo you have any special routines for eating?î
C) ìAre there any foods that you can’t eat?î
D) ìDo you eat three meals a day?î
E) ìDo you have certain foods to keep you healthy?î
17. When considering the various cultural aspects associated with death rituals, which of the
following should guide a nurse’s practice?
A) Most cultures have similar durations for the length of time a person grieves.
B) A person’s view of death is likely to be different from the original ethnic group’s
C) Responses to death and grief are fairly consistent among different cultures.
D) Rituals for burial and bereavement are likely to reflect original cultural practices.
18. A nurse is assessing an Asian client and observes several reddened and bruised areas on
the skin. Further assessment reveals that the client was using cupping to treat back pain.
The nurse understands this as which of the following?
A) Placing heated glass jars on the skin that are allowed to cool
B) Rubbing ointment into the skin with a spoon
C) Attaching smoldering herbs to acupuncture needles
D) Placing warm burning herbs directly on the skin
19. A nurse educator is reviewing the unit’s resources about religious groups and their views
about blood and blood products, organ donation, and autopsy. A member of which
group is most likely to refuse a blood transfusion?
A) Christian Scientists
B) Jehovah’s Witnesses
C) Orthodox Jews
D) Roman Catholics
20. A cardiac care nurse works with a diverse client population. The nurse would assess a
client from which cultural group for an increased effect of an antihypertensive
B) Native Americans
21. A nurse’s reflection of his practice reveals that he tends to see his own culture as the
ìgold standardî to which all other cultures should aspire. This nurse should create
learning goals to address what phenomenon?
B) Unconscious incompetence
22. A nurse is participating in an educational exercise in which she is conducting a selfexamination of her own biases. This activity addresses what construct of cultural
A) Cultural desire
B) Cultural knowledge
C) Cultural skill
D) Cultural awareness
23. A nurse is caring for a 70-year-old client from a different culture whose breast cancer
has metastasized. The nurse observes that the client tends to defer responsibility for
decision making around treatment options to her eldest son. How should the nurse
respond to this?
A) Explain the disconnect between the client’s practice and the principle of client
B) Confirm that the client wants her son to make decisions and follow those decisions
C) Attempt to dialogue with the client when her son is not present.
D) Refer the family to social work in order to further explore alternative decisionmaking practices.
24. A clinic nurse is conducting a comprehensive assessment of a 70-year-old male client of
Native American ethnicity. The nurse observes that the client rarely makes eye contact
and holds his head low during the assessment. How should the nurse best interpret this
A) The client may not understand the purpose of the assessment.
B) The client may be showing the nurse respect.
C) The client may be a victim of intimate partner violence.
D) The client may not trust the nurse’s expertise.
25. A nurse is validating assessment findings with a client, and the client proceeds to
describe some of the psychological and spiritual components that she believes underlie
her disease process. This understanding of the cause of illness is most closely associated
with which of the following?
A) Northern European cultures
B) The Western biomedical model
C) African-American culture
D) Asian cultures
26. A nurse is working with a 22-year-old woman of Asian ethnicity who has been
diagnosed with bipolar disorder. When planning culturally appropriate care, the nurse
should consider which of the following?
A) There may a lack of acceptance that the client’s behavior is abnormal.
B) The client’s family may see her illness as punishment for misdeeds.
C) The client’s family may see her psychiatric disorder as evidence of bad character.
D) There may be shame associated with having a psychiatric disorder.
27. A nurse is assessing an African-American client who has a longstanding diagnosis of
hypertension. The nurse should be aware that the client may experience a greater-thanaverage effect of what medication?
A) A diuretic
B) An angiotensin-converting enzyme inhibitor
C) A calcium channel blocker
D) A beta-adrenergic blocker
28. A nurse will be working in a clinic in South Asia for several weeks, where the majority
of residents have darkly pigmented skin. The nurse should expect a higher-than-average
incidence of what integumentary health problem?
A) Contact dermatitis
29. A nurse is relying heavily on gestures and simplified language during the assessment of
a client from another culture who speaks minimal English. During the lengthy
assessment, the nurse asks the client if she is ìokayî by making a circle with his thumb
and forefinger. The nurse should be aware of which of the following?
A) In some cultures, this gesture denotes confusion.
B) In some cultures, this gesture is offensive.
C) This gesture has meaning only in American cultures.
D) In some cultures, this gesture denotes pain.
30. A nurse admits to a colleague, ìI sometimes tend to avoid clients from other cultures
because it’s awkward and it’s usually frustrating for me and for the client.î This nurse is
likely lacking in what construct of cultural competency?
A) Cultural desire
B) Cultural knowledge
C) Cultural health
D) Cultural harmony
1. A client tells the clinic nurse that she has sought care because she has been experiencing
excessive tearing of her eyes. Which assessment should the nurse next perform?
A) Inspect the palpebral conjunctiva.
B) Assess the nasolacrimal sac.
C) Perform the eye positions test.
D) Test pupillary reaction to light.
2. When performing a client’s ophthalmoscopic exam, the nurse observes a round shape
with distinct margins. The nurse would document this as which of the following?
A) Physiologic cup
B) Optic disc
C) Retinal vessels
3. A nurse shines a light into one of the client’s eyes during an ocular exam and the pupil
of the other eye constricts. The nurse interprets this as which of the following?
A) Direct reflex
B) Optic chiasm
C) Consensual response
4. The nurse is preparing to test a client’s eyes for accommodation. The nurse would have
the client focus on an object in which sequence for this test?
A) Far, then near
B) Lateral, then near
C) Near, then far
D) Lateral, then far
5. During a health history, a 62-year-old male client reveals that he occasionally sees spots
before his eyes. The nurse interprets this finding as the result of which of the following?
A) Increased ocular pressure
B) Vitamin A deficiency
C) Normal findings for client’s age
D) Vascular spasm
6. A nurse who works at an outpatient ophthalmic clinic has a large number of clients.
Which client would be at the highest risk for developing cataracts?
A) A 55-year-old female client
B) A 40-year-old with arteriosclerosis
C) A client who has severe environmental allergies
D) A male client who is obese
7. A nurse is assessing an adult client’s eyes and vision. When performing the cover test,
the nurse would cover one of the client’s eyes and then do which of the following?
A) Ask the client to focus on a distant object, looking for movement in the other eye.
B) Ask the client to close the other eye then open that eye quickly.
C) Ask the client to follow the nurse’s finger with the other eye.
D) Ask the client to look directly at a light with the other eye.
8. The nurse is assessing a client whose electronic health record notes a diagnosis of
esotropia. When examining this client, the nurse should expect what finding?
A) Eye turning outward
B) Eye malalignment
C) Eye turning inward
D) Eye oscillating
9. A client’s history suggests a need to assess eye muscle strength and cranial nerve
function. What assessment should the nurse consequently perform?
A) Corneal light reflex test
B) Eye positions test
C) Cover test
D) Visual fields test
10. A nurse is performing an eye assessment of an 81-year-old male client. Which of the
following would the nurse document as a normal finding?
11. Which of the following would the nurse expect to assess when examining the eyes of a
client who reports a history of severe allergies?
A) Generalized redness
C) Areas of dryness
D) Nodular appearance
12. During a client’s eye assessment, the nurse is testing for consensual pupillary
constriction. Which technique should the nurse implement?
A) Hold a pencil about 12 inches from the tip of the nose.
B) Use an ophthalmoscope to inspect the inner eye.
C) Shine a light directly into one eye of the client.
D) Place a barrier between the client’s eyes.
13. A nurse is assessing the eyes of a 3-year-old child. Which finding would the nurse
document as normal?
14. A review of a client’s history reveals cranial nerve IV paralysis. Which of the following
findings would the nurse expect to assess?
A) The eye cannot look to the outside side.
B) Ptosis will be evident.
C) The eye cannot look down when turned inward.
D) The eye will look straight ahead.
15. A nurse is observing the red reflex in a client during an eye assessment. During this
component of the assessment, the client states, ìI hope you can see it because I have
cataracts.î What finding should the nurse expect?
A) Black spokes pointing inward
B) White arc around the limbus
C) Thickened bulbar conjunctiva
D) A red spot on the retina
16. A nurse in the emergency department assesses a client’s pupillary reaction and observes
pinpoint pupils. The nurse interprets this finding as suggesting which of the following?
A) Recent eye trauma
B) Narcotic use
C) Macular degeneration
D) Recent peripheral nervous system injury
17. A nurse is assessing a client who is suspected to have optic atrophy. Which of the
following assessment findings is most consistent with this diagnosis?
A) Obscured retinal vessels
B) No visible physiologic cup
C) Increased appearance of the disc vessels
D) A white appearance of the optic disc
18. A nurse is performing an eye and vision assessment on a client who has an inner ear
disorder. This disorder may contribute to what finding during the client’s eye positions
19. After teaching a group of students about the external and internal structures of the eye,
the instructor determines that the teaching was successful when the students identify
which of the following as external structures? Select all that apply.
A) Lacrimal apparatus
20. A nurse is presenting a class to a local community group about vision and eye health. As
part of the presentation, the nurse explains how visual perception occurs. Which of the
following would the nurse include in the explanation?
A) It refers to a client’s subjective appraisal of his or her vision.
B) It begins with light rays striking the retina.
C) It primarily involves the lens of the eye.
D) It allows the eyes to focus on near objects.
21. A nurse is completing a comprehensive health history of a 69-year-old woman who is a
new client of the clinic. Which of the nurse’s interview questions most directly
addresses the client’s risk for developing cataracts?
A) ìDo you exercise regularly?î
B) ìHave you ever been tested for diabetes?î
C) ìDo you ever take over-the-counter pain medications?î
D) ìAt what age did you first start wearing glasses?î
22. A client has sought care because she states that she has begun to see halos around
headlights and streetlights when she is out at night. The nurse should recognize the need
to refer the client for further assessment related to what health problem?
C) Macular degeneration
23. A factory worker has presented to the occupational health nurse with a small wood
splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm
tap water, but the splinter remains in place. What should the nurse do next?
A) Attempt to remove the splinter using sterile forceps.
B) Irrigate the eye with dilute hydrogen peroxide.
C) Arrange for worker to be promptly assessed by an eye specialist.
D) Encourage the worker to see an optometrist as soon as possible.
24. During an eye assessment, the nurse is testing a client’s visual acuity using a Snellen
chart. In order to prepare the client for this component of assessment, what instruction
should the nurse provide?
A) ìI’m going to ask you to slowly walk forward until the last line of the chart become
B) ìPlease stand at a comfortable distance from the chart and I’ll get you to read each
of the letters.î
C) ìHold this chart and start to read out the letters after covering one of your eyes.î
D) ìCover one of your eyes and then read out the letters on the chart, starting from the
25. A nurse is conducting an assessment of a client’s eyes and vision and has completed the
positions test. Following this test, the nurse will be able to document data that address
what aspects of eye health? Select all that apply.
A) Distant visual acuity
B) Near visual acuity
D) Eye muscle strength
E) Cranial nerve function
26. A nurse has completed the assessment of a client’s direct pupillary response and is now
assessing consensual response. This aspect of assessment should include which of the
A) Observing the eye’s reaction when a light is shone into the opposite eye
B) Shining a light into one eye while covering the other eye with an opaque card
C) Moving a finger into the client’s peripheral vision field and asking the client to
state when he or she sees the finger
D) Comparing the difference between the client’s dilated pupil and a constricted pupil
27. The nurse is using an ophthalmoscope to examine a client’s inner eye structures. What
action should the nurse perform in order to accurately examine the client’s optic disc?
A) Slowly approach the client’s eye from a 90-degree angle, maintaining a focus on
B) Position the scope close to the client’s eye and look through the pupil at a 15degree angle.
C) From a distance of 3 to 5 cm, examine the pupil from a 45- to 50-degree angle.
D) While looking through the ophthalmoscope, approach the client’s eye slowly from
28. A nurse is collecting subjective data during a client’s eye and vision assessment. When
asking the question, ìDo you wear sunglasses during exposure to the sun?î the nurse is
addressing a known risk factor for what health problem?
29. A nurse has taught a group of older adults about the high incidence and prevalence of
macular degeneration. What health promotion and prevention activity should the nurse
encourage these clients to perform?
A) Obtain a home version of the Snellen chart and test their vision weekly
B) Rinse their eyes with a warmed, normal saline solution three to four times per week
C) Maintain a low-sodium diet
D) Post an Amsler grid in their home and perform the test on a regular basis
30. A nurse has performed the corneal light reflex test during a client’s eye examination.
During this test, the nurse held a penlight 1 foot from the client’s eyes and appraised the
client’s eye alignment in which of the following ways?
A) By comparing the reflection of the light on the client’s eye surface
B) By comparing the speed of pupillary constriction
C) By comparing how quickly the client blinks each eyelid
D) By comparing the relative color of the sclerae before and after light exposure