Health Assessment For Nursing Practice 5th Edition by Wilson-Test Bank

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Health Assessment For Nursing Practice 5th Edition by Wilson-Test Bank

Chapter 2: Interviewing Patients to Obtain a Health History

Test Bank

 

MULTIPLE CHOICE

 

  1. Which statement or question does the nurse use during the introduction phase of the interview?
a. “I’m here to learn more about the pain you’re experiencing.”
b. “Can you describe the pain that you’re experiencing?”
c. “I heard you say that the pain is ‘all over’ your body.”
d. “What relieves the pain you are having?”

 

 

ANS:  A

 

  Feedback
A “I’m here to learn more about the pain you’re experiencing” is an example of the introduction phase when the nurse tells the patient the purpose of the interview.
B “Can you describe the pain that you’re experiencing?” is an example of part of a symptom analysis that occurs in the discussion phase.
C “I heard you say that the pain is ‘all over’ your body” is an example of a summary statement by the nurse that occurs in the summary phase.
D “What relieves the pain you are having?” is an example of part of a symptom analysis that occurs in the discussion phase.

 

 

DIF:    Cognitive Level: Apply                  REF:   8

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which statement is appropriate to use when beginning an interview with a new patient?
a. “Have you ever been a patient in this clinic before?”
b. “What is your purpose for coming to the clinic today?”
c. “Tell me a little about yourself and your family.”
d. “Did you have any difficulty finding the clinic?”

 

 

ANS:  B

 

  Feedback
A “Have you ever been a patient in this clinic before?” is a close-ended question that yields a “yes” or “no” response. This question may be asked on the first visit, but not as an opening question for a health interview.
B “What is your purpose for coming to the clinic today?” is an open-ended question that focuses on the patient’s reason for seeking care.
C “Tell me a little about yourself and your family” is an open-ended question, but it is too general, and it is at least two questions: one about the patient and another about the family.
D “Did you have any difficulty finding the clinic?” is a social question and does not focus on the patient’s purpose for the visit.

 

 

DIF:    Cognitive Level: Understand          REF:   8

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which statement by the nurse demonstrates a patient-centered interview?
a. “I need to complete this questionnaire about your medical and family history.”
b. “The hospital requires me to complete this assessment as soon as possible.”
c. “Tell me about the symptoms you’ve been having.”
d. “I’ve had the same symptoms that you’ve described.”

 

 

ANS:  C

 

  Feedback
A “I need to complete this questionnaire about your medical and family history” focuses on the nurse’s need to complete the assessment rather than the needs of the patient.
B “The hospital requires me to complete this assessment as soon as possible” focuses on the nurse’s need to meet hospital requirements rather than the needs of the patient.
C “Tell me about the symptoms you’ve been having” focuses on the needs of the patient so that the patient is free to share concerns, beliefs, and values in his or her own words.
D “I’ve had the same symptoms that you’ve described” focuses on the nurse rather than on the patient.

 

 

DIF:    Cognitive Level: Apply                  REF:   8

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which question is an example of an open-ended question?
a. “Have you experienced this pain before?”
b. “Do you have someone to help you at home?”
c. “How many times a day do you use your inhaler?”
d. “What were you doing when you felt the pain?”

 

 

ANS:  D

 

  Feedback
A “Have you experienced this pain before?” is closed-ended, which can obtain a “yes” or “no” answer to the question without any additional data.
B “Do you have someone to help you at home?” is closed-ended, which can obtain a “yes” or “no” answer to the question without any additional data.
C “How many times a day do you use your inhaler?” is closed-ended, which can obtain an answer of a specific number without any additional data.
D What were you doing when you felt the pain?” is a broadly-stated question that encourages a free-flowing, open response.

 

 

DIF:    Cognitive Level: Understand          REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A nurse suspects a female patient is a victim of physical abuse. Which response is most likely to encourage the patient to confide in the nurse?
a. “You’ve got a huge bruise on your face. Did your husband hit you?”
b. “That bruise looks tender. I don’t know how people can do that to one another.”
c. “If your boyfriend hit you, you can get a restraining order against him.”
d. “I’ve seen women who have been hurt by boyfriends or husbands. Does anyone hit you?”

 

 

ANS:  D

 

  Feedback
A “You’ve got a huge bruise on your face. Did your husband hit you?” assumes that domestic violence did occur, and the comment does not encourage the patient to divulge additional information.
B “That bruise looks tender. I don’t know how people can do that to one another” assumes that domestic violence did occur, and the comment does not encourage the patient to divulge additional information.
C “If your boyfriend has hit you, you can get a restraining order against him” assumes that domestic violence did occur, and the comment does not encourage the patient to divulge additional information.
D “I’ve seen women who have been hurt by boyfriends or husbands” is an example of a technique referred to as “permission giving” in which the nurse communicates that it is safe to discuss uncomfortable topics.

 

 

DIF:    Cognitive Level: Apply                  REF:   10

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Abuse/Neglect

 

  1. Which technique used by the nurse encourages a patient to continue talking during an interview?
a. Laughing and smiling during conversation
b. Using phrases such as “Go on,” and “Then?”
c. Repeating what the patient said, but using different words
d. Asking the patient to clarify a point

 

 

ANS:  B

 

  Feedback
A Laughing and smiling during conversation may show attentiveness during the interview, but does not encourage more talking.
B Using phrases such as “Go on” and “Then?” encourages the patient to continue talking.
C Rephrasing what the patient has said is restatement. It confirms your interpretation of what they said, but does not encourage additional talking.
D Asking the patient to clarify a point is done when the information is conflicting, vague, or ambiguous.

 

 

DIF:    Cognitive Level: Remember           REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. During the history, the patient states that she does not use many drugs. What is the nurse’s appropriate response to this statement?
a. “Tell me about the drugs you are using currently.”
b. “To some people six or seven is not many.”
c. “Do you mean prescription drugs or illicit drugs?”
d. “How often are you using these drugs?”

 

 

ANS:  A

 

  Feedback
A “Tell me about the drugs you are using currently” is an open-ended question that allows patients to provide further data.
B “To some people six or seven is not many” is a comment that does not ask a question or obtain useful data.
C “Do you mean prescription drugs or illicit street drugs?” is a closed-ended question that yields data about the type of drugs used only.
D “How often are you using these drugs?” asks about frequency of drug use, which is not useful until the drugs are known.

 

 

DIF:    Cognitive Level: Apply                  REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Lifestyle Choices

 

  1. A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The nurse suspects that the patient is noncompliant with her diet. Which response by the nurse enhances data collection in this situation?
a. “Tell me about what foods you eat and the frequency of your meals”
b. “What symptoms do you notice when your blood sugar levels are high?”
c. “You need to follow what the doctor has prescribed to manage your disease”
d. “Tell me what you know about the cause of type 2 diabetes.”

 

 

ANS:  A

 

  Feedback
A “Tell me about what foods you eat and the frequency of your meals” gathers more data from the patient to help the nurse confirm if noncompliance is the reason for the weight gain and high glucose levels.
B “What symptoms do you notice when your blood sugar levels are high?” does not help the nurse determine if the patient is noncompliant. It may be useful later when teaching the patient about her disease.
C “You need to follow what the doctor has prescribed to manage your disease” does not provide additional data for the nurse and may be viewed as authoritarian and paternalistic.
D “Tell me what you know about the cause of type 2 diabetes” assumes that the reason for the weight gain and high glucose levels is a lack of knowledge. A more therapeutic approach is to gather more data from the patient about how the diabetes has been managed.

 

 

DIF:    Cognitive Level: Apply                  REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A male patient tells the nurse that he rarely sleeps more than 4 hours a night and has not experienced any problems because of the lack of sleep. Which response by the nurse is most appropriate?
a. “That is interesting.”
b. “Only 4 hours of sleep? How do you stay awake during the day?”
c. “Really? Everyone needs more sleep than that.”
d. “Did I understand that you sleep 4 hours every night?”

 

 

ANS:  D

 

  Feedback
A “That is interesting” does not provide an opportunity for the patient to explain any reason for the number of hours of sleep.
B “Only 4 hours of sleep? How do you stay awake during the day?” questions the accuracy of the patient’s data and may not encourage the patient to give further details.
C “Really? Everyone needs more sleep than that” can be perceived as argumentative, but does not encourage further data from the patient.
D “Did I understand that you sleep 4 hours every night?” is a reflection technique that allows the nurse to confirm and obtain additional information.

 

 

DIF:    Cognitive Level: Apply                  REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which technique should the nurse use to obtain more data about a patient’s vague or ambiguous statement?
a. Laughing and smiling during conversation
b. Using phrases such as “Go on,” and “Then?”
c. Repeating what the patient has said, but using different words
d. Asking the patient to explain a point

 

 

ANS:  D

 

  Feedback
A Laughing and smiling during conversation may show attentiveness during the interview, but does not help to clarify vague information.
B Using phrases such as “Go on” and “Then?” encourages patients to continue talking, but does not help clarify.
C Rephrasing what the patient has said is restatement. It confirms your interpretation of what they said, but does not encourage additional talking.
D Asking the patient to explain a point is clarification, which is used to obtain more information about conflicting, vague, or ambiguous statements.

 

 

DIF:    Cognitive Level: Understand          REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. What does the nurse say to obtain more data about a patient’s vague statement about diet such as, “My diet’s okay”?
a. “Eating a variety of meats, fruits, and vegetables each day is important.”
b. “Give me an example of the foods you eat in a typical day.”
c. “Go on.”
d. “Does your diet meet your needs or does it need improvement?”

 

 

ANS:  B

 

  Feedback
A “Eating a variety of meats, fruits, and vegetables each day is important.” While this statement is true, it does not obtain data about what foods the patient consumes.
B “Give me an example of the foods you eat in a typical day.” This statement asks the patient to clarify the vague statement, “My diet is okay.”
C “Go on” encourages patients to continue talking, but does not help clarify what foods are consumed.
D “Does your diet meet your needs or does it need improvement?” This response does not help clarify what foods the patient eats. Also it contains two questions rather than asking one question at a time.

 

 

DIF:    Cognitive Level: Apply                  REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. While giving a history, a male patient describes several events out of order that occurred in different decades in his life. What technique does the nurse use to understand the timeline of these events?
a. State the order of events as understood and ask the patient to verify the order.
b. Draw conclusions about the order of events from data given.
c. Ask the patient to elaborate about these events.
d. Ask the patient to repeat what he said about these events.

 

 

ANS:  A

 

  Feedback
A State the order of events as understood and ask patient to verify the order is correct. This technique is useful when interviewing a patient who rambles or does not provide sequential data.
B Drawing conclusions about the order of events is interpretation. In this example, the sequence of events is more relevant than an interpretation. The nurse may have difficulty interpreting an unclear sequence of events.
C Asking the patient to elaborate about these events will not provide order to the sequence of events.
D Asking the patient to repeat what he said about these events will not necessarily provide a sequence of events.

 

 

DIF:    Cognitive Level: Understand          REF:   12

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A male patient is very talkative and shares much information that is not relevant to his history or the reason for his admission. Which action by the nurse improves data collection in this situation?
a. Terminate the interview.
b. Use closed-ended questions.
c. Ask the patient to stay on the subject.
d. Ask another nurse to complete the interview.

 

 

ANS:  B

 

  Feedback
A Terminating the interview is not beneficial to the patient and does not allow data collection.
B Using closed-ended questions is useful to obtain specific data when open-ended questions are not obtaining the needed data.
C Asking the patient to stay on the subject is not therapeutic and may result in less data collection.
D Asking another nurse to complete the interview may not be practical and interrupts the nurse-patient relationship that has been established.

 

 

DIF:    Cognitive Level: Understand          REF:   11

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A patient answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. Which response by the nurse is appropriate in this situation?
a. “Don’t cry! I’ll come back when you’ve settled down.”
b. “I only have a few more questions to ask, and then I’ll leave you alone for a while.”
c. “Everyone has ups and downs in their marriage. What problems are you having?”
d. “I see that you are upset. Is there something you’d like to discuss?”

 

 

ANS:  D

 

  Feedback
A “Don’t cry! I’ll come back when you’ve settled down” is not a therapeutic response. The nurse needs to support the patient rather than leave her.
B “I only have a few more questions to ask, and then I’ll leave you alone for a while” is not a therapeutic response. The nurse is more concerned about getting the history than the patient’s response.
C “Everyone has ups and downs in their marriage. What problems are you having?” is not a therapeutic response. The nurse is assuming there are problems in the marriage instead of collecting more data.
D “I see that you are upset. Is there something you’d like to discuss?” shows that the nurse is attentive to the patient’s feelings and does not make assumptions about the reason why the patient is crying. The crying may signify additional data the nurse needs to collect during this interview.

 

 

DIF:    Cognitive Level: Apply                  REF:   12

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. During an interview, a patient begins to cry and appears angry. Which response by the nurse is most therapeutic?
a. “This topic prompted an emotional response, tell me what you are feeling.”
b. “This topic does not usually cause such an emotional response.”
c. “Calm down and tell me what is wrong.”
d. “I will leave you alone for a few minutes so you can pull yourself together.”

 

 

ANS:  A

 

  Feedback
A Acknowledging the patient’s feelings and encouraging their expression communicates acceptance of the emotion. Crying is a natural behavior and should be permitted.
B “This topic does not usually cause such an emotional response” may be perceived by the patient as judgmental and it does not help the patient meet the current need.
C Encouraging the patient to stop crying so that the nurse can help is not supportive of the patient’s current need. The therapeutic action is to postpone further questioning until the patient is ready to proceed.
D Leaving the room so that the patient can be alone is not supportive of the patient.

 

 

DIF:    Cognitive Level: Apply                  REF:   12

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. In which situation is the nurse’s use of closed-ended questions most appropriate?
a. When clarifying vague or conflicting data
b. When obtaining a history from an overly-talkative patient
c. When encouraging a patient to elaborate on details of his or her history
d. When collecting data about the current health problem

 

 

ANS:  B

 

  Feedback
A When clarifying vague and conflicting data, the nurse needs to use open-ended questions to obtain data.
B When obtaining a history from an overly-talkative patient, a nurse can resort to closed-ended questions to complete the data collection in a timely manner.
C When encouraging the patient to elaborate on details of his or her history, the nurse needs to use open-ended questions to obtain the details.
D When collecting data about the current problem, the patient needs to describe the symptoms that brought him or her to seek help. These details are not collected with closed-ended questions.

 

 

DIF:    Cognitive Level: Understand          REF:   11| 14

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. The nurse is interviewing a woman with her husband present. The husband answers the questions for the wife most of the time. What is the most appropriate therapeutic nursing action to hear the patient’s viewpoint?
a. Continue the interview.
b. Ask the husband to step out of the room.
c. Ask another nurse to complete the interview.
d. Tell the woman to speak up for herself.

 

 

ANS:  B

 

  Feedback
A Continuing the interview is not a therapeutic action because the nurse needs to obtain the patient’s answers to the questions.
B Asking the husband to step out of the room will allow the patient to answer questions in her own way.
C Asking another nurse to complete the interview does not solve the problem that the husband is answering questions for his wife.
D Telling the woman to speak up for herself does not solve the problem and may interfere with the therapeutic relationship between the patient and the nurse.

 

 

DIF:    Cognitive Level: Remember           REF:   13

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A female Korean patient accompanied by her husband and son comes to the emergency department (ED) complaining of abdominal pain. The patient speaks and understands Korean only. Which person is the appropriate choice for the nurse to use to get a history from this patient?
a. The patient’s husband who speaks Korean and English
b. The patient’s son who speaks Korean and English
c. A male technician who works in the ED who speaks Korean and English
d. A female interpreter who speaks Korean and English and is available by phone

 

 

ANS:  D

 

  Feedback
A The patient’s husband who speaks Korean and English is not the best choice because he is a family member and may alter the meaning of what is said.
B The patient’s son who speaks Korean and English is not the best choice because he is a family member and may alter the meaning of what is said.
C A male technician working in the ED who speaks Korean and English is not a good choice because the patient may feel uncomfortable giving a history to a stranger who is male.
D A female interpreter who speaks Korean and English and is available by phone is the best choice because she can communicate with the patient and is the same gender as the patient.

 

 

DIF:    Cognitive Level: Understand          REF:   13

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity | NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which nurse demonstrates culturally competent care for a female patient from Russia?
a. Nurse A who asks the patient about cultural factors that influence health care
b. Nurse B who interacts with every patient from Russia in the same manner
c. Nurse C who learns the cultural variables of every culture, including Russia
d. Nurse D who relies on her previous experience with patients from Russia

 

 

ANS:  A

 

  Feedback
A Asking the patient about cultural factors that influence health care is demonstrating culturally competent care, along with interacting with each patient as a unique person who is a product of past experiences, beliefs, and values.
B Interacting with every patient from Russia in the same manner does not allow for the uniqueness of each person within the same culture.
C Learning the cultural variables of every group encountered can be valuable but it is impractical to learn about all cultures because each patient is unique. A better approach is to ask patients about their beliefs.
D Relying on previous experience with patients from Russia does not allow for the uniqueness of each person within the same culture.

 

 

DIF:    Cognitive Level: Understand          REF:   13

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity

 

  1. For which patient is a focused health history most appropriate?
a. A new patient at the health clinic for an annual examination
b. A patient admitted to the hospital with vomiting and abdominal pain
c. A patient at the health care provider’s office for a sport physical
d. A patient discharged 11 months ago who is being readmitted today

 

 

ANS:  B

 

  Feedback
A A new patient at the health clinic for an annual examination needs a comprehensive history that includes biographic data, reason for seeking care, present health status, past medical history, family history, personal and psychosocial history, and a review of all body.
B A patient admitted to the hospital with vomiting and abdominal pain benefits from a focused health history that limits data to the immediate problem.
C A patient with a specific need, such as a sport physical, needs a history for an episodic assessment.
D A patient discharged months ago who is being readmitted needs a history for a follow-up assessment that generally focuses on the specific problem or problems that caused the patient to be readmitted.

 

 

DIF:    Cognitive Level: Remember           REF:   14

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A patient tells the nurse at the clinic, “I can never seem to get warm lately and feel tired all the time.” The nurse records these data under which section of the health history?
a. Past health history
b. Present health status
c. Reason for seeking care (chief complaint)
d. Subjective assessment data

 

 

ANS:  C

 

  Feedback
A The past health history includes data about immunizations, surgeries, accidents, and childhood illnesses.
B The present health status includes data the nurse obtains from the patient, often using a symptom analysis in which more data are collected about the patient’s reason for seeking care.
C The reason for seeking care (chief complaint) is the patient’s reason for seeking care (also called the presenting problem). The patient’s reason for seeking care is often recorded as a direct quote.
D Subjective assessment data include information from the patient. In this example, the patient expresses the reason for seeking care, which is directly quoted and placed in quotation marks in the chief complaint section of the data sheet so that the patient’s reason for seeking care can be easily identified.

 

 

DIF:    Cognitive Level: Apply                  REF:   15

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. A patient comes to the ambulatory surgery center for an elective procedure this morning. While giving the admission history, the patient states she is allergic to latex. What is the most appropriate response by the nurse at this time?
a. Removing all latex products from the patient’s room
b. Using powdered gloves when providing care to this patient
c. Informing the surgeon that the patient has type I hypersensitivity to latex
d. Questioning the patient about symptoms experienced in the past with latex

 

 

ANS:  D

 

  Feedback
A Removing all latex products from the patient’s room is unnecessary at this time because the latex allergy has not been confirmed.
B Using powdered gloves when providing care to this patient is unnecessary at this time because the latex allergy has not been confirmed.
C Informing the surgeon that the patient has type I hypersensitivity to latex is unnecessary at this time because the latex allergy has not been confirmed.
D Questioning the patient about symptoms experienced in the past with latex is the appropriate response. When patients indicate an allergy to a medication or substance, ask them to describe what happens with exposure to determine whether the reaction is a side effect or an allergic reaction.

 

 

DIF:    Cognitive Level: Remember           REF:   15

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control: Injury Prevention

 

  1. A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a “bad reaction” to the last tetanus immunization. What is the most appropriate response by the nurse in this case?
a. Notify the health care provider that this immunization cannot be given.
b. Document that the patient is allergic to the tetanus vaccine.
c. Give the vaccine after explaining that adverse reactions are rare.
d. Ask the patient to describe the “bad reaction” to the vaccine in more detail.

 

 

ANS:  D

 

  Feedback
A The immunization should not be eliminated at this time. Additional facts are needed to determine the type of reaction the patient experienced.
B Documenting an allergy to the tetanus vaccine may be an error because there are insufficient data to make that determination at this time.
C Giving the vaccine may be an error if the patient is allergic to the vaccine and additional data indicates that may be the case.
D The nurse needs to collect more data about the reaction from the patient to determine the type of reaction experienced. The nurse is trying to assess the relationship between the “reaction” reported by the patient and an allergic reaction.

 

 

DIF:    Cognitive Level: Apply                  REF:   15

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Immunizations

 

  1. A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes?
a. Past health history
b. Present health status
c. Reason for seeking care (chief complaint)
d. History of present illness

 

 

ANS:  B

 

  Feedback
A The past health history includes categories of childhood illness, surgeries, hospitalizations, accidents or injuries, immunizations, and obstetric history.
B The present health status documents the current health conditions, which include chronic diseases and medications taken. In this case, diabetes and taking insulin are not the reason for seeking care, but need to be managed while the patient’s pneumonia is being treated because they may affect the patient’s recovery from pneumonia.
C The reason for seeking care (chief complaint) is a brief statement of the patient’s purpose for requesting the services of a health care provider.
D History of present illness further investigates the history of the present problem; best accomplished by conducting a symptom analysis.

 

 

DIF:    Cognitive Level: Remember           REF:   15

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Safe and Effective Care Environment: Collaboration with Interdisciplinary Team

 

  1. A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which question will provide data about this patient’s functional ability?
a. “When did your arthritis symptoms begin?”
b. “How has your arthritis affected your daily life?”
c. “Why did you come to the clinic today?”
d. ”How do you feel about your diagnosis of rheumatoid arthritis?”

 

 

ANS:  B

 

  Feedback
A “When did your arthritis symptoms begin?” is a question asked as part of the history, but does not collect data about functional ability.
B “How has your arthritis affected your daily life?” is a question that leads to data about the patient’s ability to perform self-care activities or functional abilities.
C “Why did you come to the clinic today?” is a question asked to obtain the chief complaint about a current problem, but does not focus directly on the functional assessment.
D “How do you feel about your diagnosis of rheumatoid arthritis?” is a question to ask in the psychosocial history, but does not focus directly on the functional assessment.

 

 

DIF:    Cognitive Level: Apply                  REF:   17

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. An example of a health promotion question included in the health history is:
a. “Do you have any allergies?”
b. “How often are you exercising?”
c. “What are you doing to relieve your leg pain?”
d. “What kind of herbs are you using?”

 

 

ANS:  B

 

  Feedback
A “Do you have any allergies?” is a question for the present health status rather than health promotion.
B “How often are you exercising?” is a question about activities patients regularly perform to maintain health.
C “What are you doing to relieve your leg pain?” is a question that is part of the symptom analysis.
D “What kind of herbs are you using?” is a question for the present health status rather than health promotion.

 

 

DIF:    Cognitive Level: Remember           REF:   17

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts sleep and has not been helped by over-the-counter cough medicines. Which question is most appropriate for the nurse to ask next?
a. “So what do you think is causing this persistent cough?”
b. “Have you tried taking sleeping pills to help you sleep?”
c. “Did you think this will just go away on its own?”
d. “What other symptoms have you noticed related to this cough?”

 

 

ANS:  D

 

  Feedback
A The answer to the question “So what do you think is causing this persistent cough?” is a guess by the patient and does not provide useful data.
B “Have you tried taking sleeping pills to help you sleep?” does not focus on the cough, which is what is disturbing the patient’s sleep.
C “Did you think this will just go away on its own?” does not provide useful data and criticizes the patient’s lack of action.
D “What other symptoms have you noticed related to this cough?” is part of a symptom analysis to provide more data.

 

 

DIF:    Cognitive Level: Apply                  REF:   15| 17

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

MULTIPLE RESPONSE

 

  1. Which data do nurses document under the heading of Past Health History? Select all that apply.
a. Father has Alzheimer disease
b. Last tetanus in 2009
c. Had chicken pox as a child
d. Drinks three to four beers each day
e. Had a dental examination 6 months ago

 

 

ANS:  B, C, E

Correct: Last tetanus is an immunization, chicken pox as a child is a childhood illness, and last examinations, including dental, are documented under the heading of Past Health History.

Incorrect: Family History documents father’s Alzheimer disease; patient drinking three to four beers each day refers to alcohol use, which is documented under the heading Personal and Psychosocial History.

 

DIF:    Cognitive Level: Understand          REF:   15-16

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which data do nurses document under the heading of Personal and Psychosocial History? Select all that apply.
a. Walks for 45 minutes each day
b. Eats meats, vegetables, and fruit at two meals daily
c. Is allergic to milk and milk products
d. Is married and has two daughters whom is he close to
e. Smokes marijuana once a week
f. Grandfather died from prostate cancer

 

 

ANS:  A, B, D, E

Correct: Walks for 45 minutes each day is documented under health promotion activity in Personal and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is documented about diet activity in Personal and Psychosocial History; is married and has two daughters whom is he close to is documented under family and social relationship activity in Personal and Psychosocial History; smokes marijuana once a week is documented under personal habits activity in Personal and Psychosocial History.

Incorrect: Allergic to milk and milk products is an allergy, which is documented under the heading Present Health Status; Grandfather died from prostate cancer is documented under the heading Family History.

 

DIF:    Cognitive Level: Understand          REF:   16-17

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications

 

  1. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports breathing problems? Select all that apply.
a. “How long have you had this problem with your breathing?”
b. “Do you have a family history of breathing problems?”
c. “Does this breathing problem come and go or is it constant?”
d. “What do you do to make your breathing better?”
e. “How does this breathing problem affect your work or daily activities?”
f. “How many packs of cigarettes do you smoke a day?”

 

 

ANS:  A, C, D, E

Correct: “How long have you had this problem with your breathing?”, “Does this breathing problem come and go or is it constant?”, “What do you do to make your breathing better?”, and “How does this breathing problem affect your work or daily activities?” are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms).

Incorrect: “Do you have a family history of breathing problems?” This question relates to the patient’s history; “How many packs of cigarettes do you smoke a day?” This question relates to the patient’s history.

 

DIF:    Cognitive Level: Apply                  REF:   15

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports headache? Select all that apply.
a. “Describe what the headache feels like?”
b. “When was your last eye examination?”
c. “What makes the headaches worse?”
d. “How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?”
e. “Do you have any symptoms with the headaches, such as nausea?”
f. “When did you first notice the headaches?”

 

 

ANS:  A, C, D, E, F

Correct: “Describe what the headache feels like?”, “What makes the headaches worse?”, “How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?”, “Do you have any symptoms with the headaches, such as nausea?”, and “When did you first notice the headaches?” are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms).

Incorrect: “When was your last eye examination?” assumes that the headaches are related to a vision problem. Last eye examination is documented in the history under the heading of Past Health History.

 

DIF:    Cognitive Level: Apply                  REF:   15

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. Which questions are pertinent for a nurse to ask a patient while performing a review of the cardiovascular system? Select all that apply.
a. “Do you remember what your last cholesterol value was?”
b. “Have you had chest pain or shortness of breath?”
c. “Do you have trouble breathing when you lie down?”
d. “Are your feet cold, numb, or do they change color?”
e. “How much do you weigh?”
f. “Have you noticed edema in your ankles at the end of the day?”

 

 

ANS:  B, C, D, F

Correct: “Have you had chest pain or shortness of breath?”, “Do you have trouble breathing when you lie down?”, “Are your feet cold, numb, or do they change color?”, and “Have you noticed edema in your ankles at the end of the day?” are questions asked to give the patient an opportunity to report symptoms of the cardiovascular system.

Incorrect: “Do you remember what your last cholesterol value was?” relates to a lab value, which is objective data not documented in the history; “How much do you weigh?” is objective data not documented in the history.

 

DIF:    Cognitive Level: Remember           REF:   18

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

Chapter 12: Heart and Peripheral Vascular System

Test Bank

 

MULTIPLE CHOICE

 

  1. A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse’s appropriate response? The 128 represents the pressure in your blood vessels when:
a. “The ventricles relax and the aortic and pulmonic valves open.”
b. “The ventricles contract and the mitral and tricuspid valves close.”
c. “The ventricles contract and the mitral and tricuspid valves open.”
d. “The ventricles relax and the aortic and pulmonic valves close.”

 

 

ANS:  B

 

  Feedback
A The aortic and pulmonic valves open during systole, but ventricles fill during diastole.
B During systole the ventricles contract, creating a pressure that closes the atrioventricular (AV) valves (mitral and tricuspid).
C During systole the ventricles contract, creating a pressure that closes the AV valves (mitral and tricuspid).
D The ventricles are relaxed and the aortic and pulmonic valves close during diastole, rather than systole.

 

 

DIF:    Cognitive Level: Understand          REF:   225

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a cause of this heart rate?
a. Sinoatrial (SA) node failure
b. Atrial bradycardia
c. A well-conditioned heart muscle
d. Left ventricular hypertrophy

 

 

ANS:  A

 

  Feedback
A If the SA node is ineffective, the atrioventricular  node may initiate contraction, but at a rate of 40 to 60 beats/min.
B The heart rate reflects the ventricular rate rather than the atrial rate.
C Although well-conditioned athletes may have slower heart rates, this rate is too slow for even an athlete.
D Left ventricular hypertrophy alters the strength of contraction rather than the heart rate.

 

 

DIF:    Cognitive Level: Apply                  REF:   226

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

 

  1. While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?
a. An extra beat just before the S2 heart sound heard during auscultation
b. A raspy machine-like or blowing sound heard during auscultation
c. A prominent thrust of the heart against the chest wall felt on palpation
d. A visible indentation of pericardial tissue noted during inspection

 

 

ANS:  B

 

  Feedback
A An extra beat just before the S1 heart sound heard during auscultation is a description of the S4 heart sound that occurs when there is hypertrophy of the ventricle.
B A raspy machine-like or blowing sound heard during auscultation is a description of a murmur that can develop after rheumatic heart disease.
C A prominent thrust of the heart against the chest wall felt on palpation is a description of a heave, which may occur from left ventricular hypertrophy due to increased workload.
D A visible indentation of pericardial tissue noted during inspection is a description of a retraction that begins in the intercostal spaces and occurs with increased respiratory effort.

 

 

DIF:    Cognitive Level: Analyze               REF:   229| 259

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient’s chest pain?
a. Stable angina
b. Esophageal reflux disease
c. Mitral valve prolapse
d. Costochondritis

 

 

ANS:  D

 

  Feedback
A Physical exertion, emotional stress, and cold worsen the chest pain associated with stable angina.
B A spicy or acidic meal, alcohol, or lying supine may worsen the chest pain associated with esophageal reflux.
C Only occasional position changes worsen the chest pain associated with mitral valve prolapse.
D Coughing, deep breathing, laughing, and sneezing worsen the chest pain associated with costochondritis.

 

 

DIF:    Cognitive Level: Apply                  REF:   230-231

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. The patient describes her chest pain as “squeezing, crushing, and 12 on a scale of 10.” This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms?
a. Tachycardia, tachypnea, and hypertension
b. Dyspnea, diaphoresis, and palpitations
c. Hyperventilation, fatigue, anorexia, and emotional strain
d. Fever, dyspnea, orthopnea, and friction rub

 

 

ANS:  B

 

  Feedback
A Tachycardia, tachypnea, and hypertension are symptoms associated with cocaine-induced chest pain.
B Dyspnea, diaphoresis, and palpitations are symptoms associated with unstable angina.
C Hyperventilation, fatigue, anorexia, and emotional strain are symptoms associated with panic disorder.
D Fever, dyspnea, orthopnea, and friction rub are symptoms associated with pericarditis.

 

 

DIF:    Cognitive Level: Analyze               REF:   230-231

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound?
a. A systolic murmur
b. An S3 heart sound
c. A friction rub
d. An S4 heart sound

 

 

ANS:  C

 

  Feedback
A Most systolic murmurs are caused by obstruction of the outflow of the semilunar valves or by incompetent AV valves.
B An S3 heart sound occurs when there is heart failure.
C Two classic findings of pericarditis are pericardial friction rub and chest pain.
D An S4 heart sound occurs when there is hypertrophy of the ventricle.

 

 

DIF:    Cognitive Level: Apply                  REF:   230-231

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. Which patient’s statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina?
a. “No, I have not done anything to strain chest muscles.”
b. “If I take a deep breath, the pain gets much worse.”
c. “This pain feels like there’s an elephant sitting on my chest.”
d. “Whenever this pain happens, it goes right away if I lie down.”

 

 

ANS:  B

 

  Feedback
A Chest pain from muscle strain may be aggravated by movement of arms.
B The chest pain from pericarditis is aggravated by deep breathing, coughing, or lying supine.
C “This pain feels like there’s an elephant sitting on my chest” is associated with a myocardial infarction.
D Chest pain relieved by rest occurs with angina.

 

 

DIF:    Cognitive Level: Analyze               REF:   230-231

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination?
a. Flat jugular neck veins
b. Red, shiny skin on the legs
c. Weak, thready peripheral pulses
d. Edema of the feet and ankles

 

 

ANS:  D

 

  Feedback
A Flat jugular veins indicate a fluid deficit, which is not associated with dyspnea.
B Red, shiny skin on the legs is associated with peripheral arterial disease and is not associated with dyspnea.
C Weak, thready peripheral pulses indicate fluid deficit, which is not associated with dyspnea.
D This patient may have heart failure. Edema of the feet occurs with right ventricular heart failure. Dyspnea occurs with left ventricular heart failure.

 

 

DIF:    Cognitive Level: Analyze               REF:   230| 232-233

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. A nurse is assessing a patient’s peripheral circulation. Which finding indicates venous insufficiency of this patient’s legs?
a. Paresthesias and weak, thin peripheral pulses
b. Leg pain that can be relieved by walking
c. Edema that is worse at the end of the day
d. Leg pain that increases when the legs are lowered

 

 

ANS:  C

 

  Feedback
A Paresthesias and weak, thin peripheral pulses are characteristics of arterial insufficiencies rather than venous.
B Pain caused by arterial insufficiency gets worse by walking, because walking requires additional arterial blood.
C Dependent edema is an indication of venous insufficiency.
D Arterial pain is relieved by lowering the leg and aggravated by elevating the legs.

 

 

DIF:    Cognitive Level: Apply                  REF:   233| 255

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?
a. 1+ edema of the feet and ankles bilaterally
b. The circumference of the right leg is larger than the left leg
c. Patchy petechiae and purpura of the lower extremities
d. Cool feet with capillary refill of toes greater than 3 seconds

 

 

ANS:  D

 

  Feedback
A Edema of 1+ of the feet and ankles bilaterally is an indication of a venous problem rather than an arterial problem.
B When one leg is larger in circumference than the other, it could be due to lymphedema or a deep vein thrombosis.
C Petechiae and purpura of the lower extremities indicate a bleeding problem, such as low platelets, rather than an arterial problem.
D The pain while walking that is relieved by rest is called intermittent claudication and is an indication of arterial insufficiency. Cool feet and prolonged capillary refill also occur due to arterial insufficiency.

 

 

DIF:    Cognitive Level: Analyze               REF:   233| 241

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. How does a nurse accurately palpate carotid pulses?
a. Two fingers of each hand are placed firmly over the right and left temples at the same time.
b. One finger is placed gently in the space between the biceps and triceps muscles.
c. Two fingers are placed at the thumb side of the forearm at the wrist.
d. One finger is placed along the right and then the left medial sternocleidomastoid muscle.

 

 

ANS:  D

 

  Feedback
A Two fingers of each hand placed firmly over the right and left temples at the same time is the correct procedure for palpating the temporal pulse.
B One finger placed gently in the space between the biceps and triceps muscles is the correct procedure for palpating the brachial pulse.
C Two fingers placed at the thumb side of the forearm at the wrist is the correct procedure for palpating the radial pulse.
D One finger placed along the right and then the left medial sternocleidomastoid muscle is the correct procedure for palpating the carotid pulses, checking each side separately.

 

 

DIF:    Cognitive Level: Understand          REF:   234-235

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

 

  1. To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm?
a. “Rhythm 100 beats/min”
b. “Irregular rhythm”
c. “Rhythm noted at +2”
d. “Bounding rhythm”

 

 

ANS:  B

 

  Feedback
A This notation refers to the rate rather than the rhythm.
B The rhythm should be an equal pattern or spacing between beats. Irregular rhythms without any pattern should be noted.
C This notation refers to the amplitude rather than the rhythm.
D This notation refers to the contour rather than the rhythm.

 

 

DIF:    Cognitive Level: Apply                  REF:   236

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. A nurse expects which finding during a cardiovascular assessment of a healthy adult?
a. Visible, consistent pulsations of the jugular vein
b. Pink nail beds with a 90-degree angle at the base
c. Capillary refill of the toes greater than 5 seconds
d. Bruits heard on auscultation of the carotid arteries

 

 

ANS:  A

 

  Feedback
A Visible, consistent pulsations of the jugular vein is an expected finding.
B Pink nail beds with a 90-degree angle at the base is not a normal finding; the angle at the base should be 160 degrees.
C Capillary refill of the toes greater than 5 seconds is not a normal finding. Capillary refills should be 2 seconds or less.
D Bruits heard on auscultation of the carotid arteries is not a normal finding. Bruits indicate occlusion of a blood vessel.

 

 

DIF:    Cognitive Level: Apply                  REF:   235| 237

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. Which pulse may be a challenge for a nurse to palpate?
a. Temporal
b. Femoral
c. Popliteal
d. Dorsalis pedis

 

 

ANS:  C

 

  Feedback
A The temporal pulse is palpated over the temporal bone on each side of the head.
B For the femoral pulse, palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac.
C For the popliteal pulse, palpate the popliteal artery behind the knee in the popliteal fossa to assess perfusion. This pulse may be difficult to find.
D For the dorsalis pedis pulse, palpate on the inner aspect of the ankle below and slightly behind the medial malleolus (ankle bone).

 

 

DIF:    Cognitive Level: Understand          REF:   241-242

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

 

  1. When assessing a patient with aortic valve stenosis, the nurse listens for which sound to detect a thrill?
a. Sustained thrust of the heart against the chest wall during systole
b. Visible sinking of the tissues between and around the ribs
c. Fine, palpable vibration felt over the precordium
d. Bounding pulse noted bilaterally

 

 

ANS:  C

 

  Feedback
A A sustained thrust of the heart against the chest wall during systole is a description of a lift.
B A visible sinking of the tissues between and around the ribs is a description of a retraction.
C A thrill is a palpable vibration over the precordium or artery.
D A thrill feels like a palpable vibration rather than a bounding pulse.

 

 

DIF:    Cognitive Level: Understand          REF:   243| 248

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. A nurse is having difficulty auscultating a patient’s heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds?
a. Lie in a supine position.
b. Cough.
c. Hold his or her breath for a few seconds.
d. Sit up and lean forward.

 

 

ANS:  C

 

  Feedback
A Lying in a supine position will not reduce the noise of breathing.
B Coughing may clear some secretions, but when the lung sounds are so noisy that the heart sounds are difficult to hear, coughing is not sufficient to eliminate the noise from respirations.
C Holding the breath for a few seconds eliminates the noise of breathing long enough to hear several cardiac cycles of heart sounds. The holding of the breath can be repeated if needed to hear the heart sounds again.
D Sitting up and leaning forward brings the heart closer to the thoracic wall, but will not eliminate noise produced by the lungs.

 

 

DIF:    Cognitive Level: Analyze               REF:   244

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. While assessing edema on a male patient’s lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient’s leg. How does the nurse document this finding?
a. No edema
b. 1+ edema
c. 2+ edema
d. 3+ edema

 

 

ANS:  B

 

  Feedback
A No pit left after palpation indicates no edema.
B A barely perceptible pit is detected after palpation.
C A deeper pit that rebounds in a few seconds after palpation is 2+ edema.
D A deep pit that rebounds in 10 to 20 seconds after palpation is 3+ edema.

 

 

DIF:    Cognitive Level: Apply                  REF:   238

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter that corresponds to the correct stethoscope placement.
a. A
b. B
c. D
d. E

 

 

ANS:  D

 

  Feedback
A A is the location of the aortic valve area—second intercostal space, right sternal border.
B B is the location of the pulmonic valve area—fifty-second intercostal space, left sternal border.
C D is the location of the tricuspid valve area—fourth intercostal space, left sternal border.
D E is the location of the mitral valve area—the fifth intercostal space, midclavicular line.

 

 

DIF:    Cognitive Level: Understand          REF:   245-246

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?
a. Pulmonic
b. Tricuspid
c. Mitral
d. Aortic

 

 

ANS:  B

 

  Feedback
A Pulmonic valve sounds are best heard in the second intercostal space at the left of the sternal border.
B Tricuspid valve sounds are best heard in the fourth intercostal space at the left of the sternal border.
C Mitral valve sounds are best heard in the fifth intercostal space at the midclavicular line.
D Aortic valve sounds are best heard in the second intercostal space at the right of the sternal border.

 

 

DIF:    Cognitive Level: Remember           REF:   245-246

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

 

  1. A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment?
a. S4 heart sound
b. Clubbing of fingers
c. Splitting of the S1 heart sound
d. Pericardial friction rub

 

 

ANS:  A

 

  Feedback
A An S4 heart sound signifies a noncompliant or “stiff’’ ventricle. Coronary artery disease is a major cause of a stiff ventricle.
B Clubbing of fingers occurs due to chronic hypoxia rather than a stiff ventricle.
C Splitting of the S1 heart sound indicates a valve problem rather than ventricular hypertrophy. When the mitral and tricuspid valves do not close at the same time, S1 sounds as if it were split into two sounds instead of one.
D Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.

 

 

DIF:    Cognitive Level: Apply                  REF:   225-226| 248

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. What does the S2 heart sound represent?
a. The beginning of systole.
b. The closure of the aortic and pulmonic valves.
c. The closure of the tricuspid and mitral values
d. A split heard sound on exhalation

 

 

ANS:  B

 

  Feedback
A The beginning of systole is the S1 heart sound.
B The second heart sound is made by the closing of these valves, which indicates the beginning of diastole.
C The tricupid and mitral valves create the S1 heart sound.
D A split sound on exhalation is not a correct statement.  

 

 

DIF:    Cognitive Level: Remember           REF:   226| 244

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. How is the first heart sound (S1) created?
a. Pulmonic and tricuspid valves close.
b. Mitral and aortic valves close.
c. Aortic and pulmonic valves close.
d. Mitral and tricuspid valves close.

 

 

ANS:  D

 

  Feedback
A The pulmonic and tricuspid valves are the valves of the right side of the heart, and they do not close simultaneously in the cardiac cycle.
B The mitral and aortic valves are the valves of the left side of the heart, and they do not close simultaneously in the cardiac cycle.
C The aortic and pulmonic valves are the semilunar valves that create the second heart sound.
D The first heart sound (S1) is made by the closing of the mitral (M1) and tricuspid (T1) valves.

 

 

DIF:    Cognitive Level: Remember           REF:   226| 244

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve?
a. Second intercostal space, right sternal border
b. Second intercostal space, left sternal border
c. Fourth intercostal space, left sternal border
d. Fifth intercostal space, left midclavicular line

 

 

ANS:  A

 

  Feedback
A Second intercostal space, right sternal border is the location for listening to the aortic valve.
B Second intercostal space, left sternal border is the location for listening to the pulmonic valve.
C Fourth intercostal space, left sternal border is the location for listening to the tricuspid valve.
D Fifth intercostal space, left midclavicular line is the location for listening to the mitral valve.

 

 

DIF:    Cognitive Level: Apply                  REF:   244-246

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

 

  1. A nurse who is auscultating a patient’s heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding?
a. An opening snap
b. A diastolic murmur
c. A systolic murmur
d. A pericardial friction rub

 

 

ANS:  C

 

  Feedback
A An opening snap is caused by the opening of the mitral or tricuspid valve and is an abnormal sound heard in diastole when either valve is thickened, stenotic, or deformed. The sounds are high pitched and occur early in diastole.
B A diastolic murmur is heard after the S2 heart sound at the beginning of diastole.
C The blowing sound is a murmur. The nurse determines whether it is a systolic or a diastolic murmur based on where it is heard during the cardiac cycle. S1 indicates the beginning of systole; the sound is made by the closing of the mitral and tricuspid valves, which is followed by ventricular contraction or systole.
D Pericardial friction rubs have a rubbing sound that is usually present in both diastole and systole, and is best heard over the apical area.

 

 

DIF:    Cognitive Level: Apply                  REF:   248-249

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. A nurse determines that a patient’s jugular venous pressure is 3.5 inches. What additional data does the nurse expect to find?
a. Weight loss
b. Tented skin turgor
c. Peripheral edema
d. Capillary refill greater than 5 seconds

 

 

ANS:  C

 

  Feedback
A Weight loss occurs with loss of fluid rather than fluid overload.
B Tented skin turgor occurs with fluid loss rather than fluid overload.
C The pressure should not rise more than 1 inch (2.5 cm) above the sternal angle. A pressure of 3.5 inches indicates fluid volume excess, which causes peripheral edema due to excessive fluid in blood vessels.
D Capillary refill greater than 5 seconds occurs with arterial insufficiency rather than fluid overload.

 

 

DIF:    Cognitive Level: Analyze               REF:   252-253| 260-261

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. How does a nurse assess the competence of venous valves in patients who have varicose veins?
a. Notes how quickly veins fill after lifting one leg above the level of the heart
b. Assesses for Homan sign in both lower extremities while the patient is supine
c. Assesses capillary refill on the toes of both feet while the patient is sitting in the chair
d. Measures the circumference of both calves and compares the results

 

 

ANS:  A

 

  Feedback
A Noting how quickly veins fill after lifting one leg above the level of the heart is the procedure to test for incompetent veins.
B Homan sign is an unreliable test for deep vein thrombosis.
C Assessing capillary refill assesses perfusion (blood flow from arteries) rather than competence of venous valves.
D Measuring the circumference of both calves and comparing the results is used to assess deep vein thrombosis.

 

 

DIF:    Cognitive Level: Apply                  REF:   255

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. Which patient does the nurse identify as the one at greatest risk for hypertension?
a. Woman with coronary artery disease
b. Hispanic male
c. Obese male with diabetes mellitus
d. Postmenopausal woman

 

 

ANS:  C

 

  Feedback
A Although hypertension is a risk factor for coronary artery disease, coronary artery disease is not a risk factor for hypertension.
B Although male gender is a risk factor, African-American men have a greater risk than Hispanic men.
C Obese men with diabetes mellitus have three risk factors: obesity, gender, and comorbidity of diabetes mellitus.
D Postmenopausal women do not have an increased risk for developing hypertension.

 

 

DIF:    Cognitive Level: Apply                  REF:   260

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs

 

  1. After two separate office visits, the nurse suspects that a patient is developing Stage 1 hypertension based on which consecutive blood pressure readings?
a. Visit 1, 118/78; Visit 2, 116/76
b. Visit 1, 130/88; Visit 2, 134/88
c. Visit 1, 144/92; Visit 2, 150/90
d. Visit 1, 162/100; Visit 2, 166/104

 

 

ANS:  C

 

  Feedback
A These readings are within normal limits.
B These readings are prehypertension because the systolic pressures are 120 to 139 and diastolic pressures are greater than 80 mm Hg.
C These readings are stage 1 because the systolic pressures are 140 to 159 and diastolic pressures are 90 mm Hg or greater.
D These readings are stage 2 because the systolic pressures are greater than 160 and diastolic pressures are 100 mm Hg or greater.

 

 

DIF:    Cognitive Level: Analyze               REF:   261

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

MULTIPLE RESPONSE

 

  1. During a health fair, the nurse is alert for which risk factors for hypertension? Select all that apply.
a. Excessive protein intake
b. Having parents with hypertension
c. Excessive alcohol intake
d. Being Asian
e. Experiencing persistent stress
f. Elevated serum lipids

 

 

ANS:  B, C, E, F

Correct: These are all risk factors for hypertension.

Incorrect: Excessive protein is not a risk factor for hypertension, but excessive sodium intake is a risk factor. Being Asian is not a risk factor, but being African-American is a risk factor.

 

DIF:    Cognitive Level: Analyze               REF:   261

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems

 

  1. A patient with heart failure reports having a cough with frothy sputum and awakening during the night to urinate. Based on this information, what abnormal data might this nurse expect to find during an examination? Select all that apply.
a. S4 heart sound
b. Dyspnea
c. Jugular vein distention
d. Pericardial friction rub
e. Edema of ankle and feet at the end of the day
f. S3 heart sound

 

 

ANS:  B, C, E, F

Correct: All of these manifestations are consistent with fluid overload that occurs in heart failure because the cardiac output is decreased.

Incorrect: S4 heart sounds signifies a noncompliant or “stiff’’ ventricle. Hypertrophy of the ventricle precedes a noncompliant ventricle. Also, coronary artery disease is a major cause of a stiff ventricle. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.

 

DIF:    Cognitive Level: Analyze               REF:   230| 233| 238| 247| 252-253| 260

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

 

  1. What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply.
a. Heart rate of 102 beats/min
b. S1 and S2 present with regular rhythm
c. Capillary refill greater than 3 seconds
d. Blood pressure of 124/86
e. Warm, elastic turgor
f. Pulse of smooth contour with 2+ amplitude

 

 

ANS:  B, E, F

Correct: These are all expected findings.

Incorrect: A heart rate of 102 beats/min is tachycardia. Capillary refill should be 2 seconds or less. Blood pressure of 124/86 is prehypertension. Normal is less than 120 and less than 80 mm Hg.

 

DIF:    Cognitive Level: Analyze               REF:   238-239| 241| 244| 259

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

COMPLETION

 

  1. A patient’s blood pressure using the posterior tibial pulse is 104/72 while blood pressure using the brachial pulse is 112/84. This patient’s ankle-brachial index (ABI) is _____.

 

ANS:

0.92

Posterior tibial systolic pressure (104) divided by the brachial systolic pressure (112) = 0.92. The systolic pressures are the numbers used to calculate the ABI.

 

DIF:    Cognitive Level: Apply                  REF:   256

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

Chapter 24: Adapting Health Assessment to the Hospitalized Patient

Test Bank

 

MULTIPLE CHOICE

 

  1. Development of which complication is considered a never event?
a. Fever
b. Atelectasis
c. Pressure ulcer
d. Thrombophlebitis

 

 

ANS:  C

 

  Feedback
A Fever is a common occurrence in ill patients that may indicate inflammation or infection.
B Atelectasis is collapse of alveoli that may occur due to the patient’s hypoventilation, such as after surgery.
C Pressure ulcer is termed a never event because it refers to preventable, medical errors that should never occur.
D Thrombophlebitis is inflammation of veins that may occur due to immobility.

 

 

DIF:    Cognitive Level: Understand          REF:   545

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. For which patient does the nurse make assessment of the oral mucous membrane a priority?
a. The patient who has an arteriovenous (AV) fistula
b. The patient who has a gastrostomy tube
c. The patient who uses a Ventimask
d. The patient who has a colostomy

 

 

ANS:  B

 

  Feedback
A The AV fistula is required by patients who need hemodialysis for kidney failure. They are able to drink fluids by mouth.
B Which patient can drink fluids by mouth is the distinguishing fact. This patient has this gastrostomy tube because he or she has difficulty swallowing. Thus this patient may not have fluids by mouth, which increases the risk for dry mucous membranes and makes the assessment most important compared with the other listed patients.
C The Ventimask fits over the nose and mouth to deliver oxygen. This patient is able to drink fluids by mouth.
D This patient has had part or all of the colon removed, but this patient is able to drink fluids by mouth.

 

 

DIF:    Cognitive Level: Apply                  REF:   550

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes?
a. Palpate the popliteal pulse of the left leg.
b. Palpate the posterior tibial pulse of the left leg.
c. Assess movement and sensation of the left toes.
d. Assess the capillary refill of the left toes.

 

 

ANS:  D

 

  Feedback
A This pulse is above the foot and does not indicate perfusion of the foot.
B The pulse is not palpable because it is covered by the cast.
C This assessment is important for this patient but assesses neurologic function rather than perfusion.
D The presence of capillary refill in less than 2 seconds indicates perfusion of the left foot when the dorsalis pedis pulse cannot be palpated.

 

 

DIF:    Cognitive Level: Understand          REF:   553

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. A nurse uses the Glasgow Coma Scale to assess which patient?
a. The patient who has a new onset of quadriplegia
b. The patient who has tonic-clonic seizures
c. The patient who requires stimuli for responses
d. The patient who has dementia

 

 

ANS:  C

 

  Feedback
A Although this patient is paralyzed, he or she is conscious. The Glasgow Coma Scale would not yield useful data about this patient.
B Although this patient may be unconscious during seizures, consciousness will return. The Glasgow Coma Scale would not yield useful data about this patient.
C The Glasgow Coma Scale is applicable only to patients who are unconscious, meaning they do not respond unless stimulated in some way from touch to pain.
D This patient is not unconscious. The Glasgow Coma Scale would not yield useful data about this patient.

 

 

DIF:    Cognitive Level: Apply                  REF:   555-556

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. During the assessment, the nurse determines that the patient’s Glasgow Coma Scale score is 15. What is the meaning of this number for this patient?
a. This patient is fully conscious.
b. This patient has movement but does not open the eyes or speak.
c. This patient is unable to respond to any stimuli.
d. This patient opens the eyes but does not speak or move.

 

 

ANS:  A

 

  Feedback
A A score of 15 is the expected value for the Glasgow Coma Scale.
B This patient would score a 9 on the Glasgow Coma Scale.
C This patient would score a 3 on the Glasgow Coma Scale.
D This patient would score a 4 on the Glasgow Coma Scale.

 

 

DIF:    Cognitive Level: Understand          REF:   556

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

  1. When performing a neurologic assessment of a male patient, a nurse discovers that shouting and shaking are necessary to arouse the patient enough to assess his neurologic status. After the patient answers questions about who he is and squeezes the nurse’s hand as requested, he returns to “sleep.” How does the nurse document this patient’s level of consciousness?
a. Lethargic
b. Obtunded
c. Stuporous
d. Semicomatose

 

 

ANS:  B

 

  Feedback
A Lethargic patients can be aroused by saying their names and touching them.
B Obtunded patients require shouting and vigorous shaking to arouse them; they carry out requests while awake, but return to “sleep” when stimuli stops.
C Stuporous patients require painful stimuli to respond and the response usually is a withdrawal from the source of pain.
D Semicomatose patients require painful stimuli and respond with abnormal flexion or extension.

 

 

DIF:    Cognitive Level: Understand          REF:   555

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

MULTIPLE RESPONSE

 

  1. What data do nurses collect when assessing a patient’s wound? Select all that apply.
a. Skin turgor
b. Width, length, and depth
c. Presence of pulsations
d. Wound color
e. Presence of edema
f. Drainage color

 

 

ANS:  B, D, E, F

Correct: These data are collected when assessing a wound.

Incorrect: Skin turgor is assessed in intact skin rather than wounds. Presence of pulsations is not indicated when assessing a wound.

 

DIF:    Cognitive Level: Understand          REF:   546

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. Which patient using respiratory equipment requires skin assessment? Select all that apply.
a. A patient using a nasal cannula
b. A patient with a tracheostomy
c. A patient using an incentive spirometer
d. A patient using a Ventimask
e. A patient with an IV

 

 

ANS:  A, B, D

Correct: Patients using a nasal cannula need inspection of the nares and behind the helix of the ears. Patients with a tracheostomy need inspection of skin around the stoma where the tracheostomy tube enters the trachea. Patients using a Ventimask need inspection of skin where the mask comes in contact with the face and behind the helix of the ears. Patients with IVs need inspection of the skin to verify the catheter is secured and to assess for redness or edema.

Incorrect: Using an incentive spirometer requires the patient to take deep breaths, thus a skin assessment is not indicated.

 

DIF:    Cognitive Level: Understand          REF:   547-548

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

 

  1. Which tube interferes with hearing lung sounds during auscultation? Select all that apply.
a. Gastrostomy tube
b. Chest tube
c. Nasogastric tube
d. Tracheostomy tube
e. Oral endotracheal tube

 

 

ANS:  B, C

Correct: When attached to suction, chest and nasogastric tubes can create sounds that may mimic lung sounds.

Incorrect: Gastrostomy tube is in the stomach and not attached to suction that might create a false sound similar to lung sounds. Tracheostomy tube is not attached to suction that might create a false sound similar to lung sounds. Oral endotracheal tubes are not attached to suction that might create a false sound similar to lung sounds.

 

DIF:    Cognitive Level: Understand          REF:   548| 551

TOP:   Nursing Process: Assessment

MSC:  NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

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