Head to Toe Assessment (Module 1)

Question 1

A patients spiritual values and beliefs would have the greatest influence on?

Answer 1

Response to illness

Question 2

List the steps the RN takes when beginning the interview process for the health hx.

Answer 2

A. Prepares the environment 
B. Identifies patient by formal name
C. States nurses full name and status
D. Identifies purpose of the interview
E. Clarify expectation of interview

Question 3

Which nursing interventions are appropriate when the RN performs a health assessment on a patient who is confused to time and place?

Answer 3

A. Keep communication simple and concrete
B. Minimize distractions
C. Sit and maintain eye contact

Question 4

Which question is most appropriate to ask a patient when exploring the reason for seeking healthcare in an acute care hospital?

Answer 4

“Can u tell me why u were admitted into the hospital?”

Question 5

Which is an example of subjective data?

Answer 5

A. Smokes two packs of cigarettes per day for 30 years
B. Pain level is 4 on the 0-10 verbal scale
C. Nauseated after high fat meals

Question 6

Which is an example of objective data?

Answer 6

A. Blood pressure164/85
B. SPO2=90%
C. Gait is unsteady

Question 7

Which question should the RN ask when gathering information about a patients stress and coping patterns?

Answer 7

A. What makes u anxious or causes u to worry?
B. What is the reason u take herbal supplements?
C. How do u handle difficult situations?

Question 8

Which questions are most appropriate for the RN to ask a patient regarding family medical hx?

Answer 8

A. What was the cause of ur family members death?

B. What health issues are ur family members being treated for?

Question 9

What is an appropriate f/u question when a patient tells the RN “I only eat certain foods” during the health hx?

Answer 9

What is included in ur typical meal?

Question 10

The RN notices that the patient has difficulty communicating verbally and is slow to respond. What is one evidence based activity the RN can perform to obtain accurate health hx?

Answer 10

Restating answers to help validate what the RN heard.

Question 11

Which statement by a woman in her first trimester of pregnancy requires the RN to seek further information from the patient?

Answer 11

I wish my family and friends lived closer to me.

Question 12

A one-year-old child is seen in the emergency department after a fall at home. Which of the following findings from the health history would make the RN suspicious of maltreatment?

Answer 12

The child has a history of bone fractures.

Question 13

A patient with schizophrenia taking The anti-psychotropic medication Zyprexa has increased thirst and urinary frequency and a 15 pound weight gain in one month. Which lab test would the RN anticipate being performed?

Answer 13

Hemoglobin A-1 C

Glycated Hgb

Question 14

What information should the RN include to validate a patients identity prior to providing treatment in an acute care setting?

Answer 14

• two patient identifiers are required.
• The patients full name
• The patient’s date of birth
• The patient’s ID or medical record number

Question 15

What information should the RN include to validate a patients identity prior to providing treatment in an long term care setting?

Answer 15

-A current photograph of the resident can be used as a identifier.

Question 16

List four sources of data the RN should use to gather information regarding the patient.

Answer 16

1. The patient
2. The family or significant other
3. Other healthcare professionals
4. Laboratory and diagnostic testing

Question 17

Identify three activities the RN performs prior to obtaining a health history?

Answer 17

1. Reads current and past medical history reports
2. Ensures environment is private and relaxed
3. Positions self at eye level with patient
4. Approaches each patient with a sensitive open mind

Question 18

Which of Mrs. Feinstein’s statement obtained during the health history is significant to her current medical health problem?

Answer 18

“I feel at home 2 weeks ago”

Question 19

Which data from Mrs. Feinstein’s health history is significant to her current health problem?

Answer 19

Feeling unsteady on her feet

Question 20

Based on Mrs. Feinstein’s health history, what are her personal risk factors for falling? Select all that apply.

Answer 20

1. Verbal report of being unsteady

2. Prescribed anti-hypertensive medications

Question 21

Which of the following actions taken by Mrs. Feinstein prior to admission is associated with a decreased risk for falling? Select all that apply.

Answer 21

Has a yearly eye exam, Exercises regularly, Removed scattered rugs

Question 22

Which personal health history information of Mrs. Feinstein would support a special dietary consideration? Select all that apply.

Answer 22

History of hypertension, Ethnicity

Question 23

Based on the findings from the health history on Mrs. Feinstein, which of the body systems require focused attention during the physical assessment? Select all that apply.

Answer 23

Cardiovascular, Musculoskeletal, Respiratory

Question 24

What additional question should the RN ask Mrs. Feinstein when she identifies her daughter as her health care agent?

Answer 24

“Do you have a copy of the form to place in your record?”

Question 25

When the RN initially interviews the patient on admission to a health care facility, what information would be indicated for the medication reconciliation process?

Answer 25

A.	Medication Name
B.	Dose
C.	Frequency
D.	Last dose taken
E.	Route 
F.	Purpose

Question 26

A patient asks “What is an advanced directive?” What is the appropriate response by the RN?

Answer 26

Legal documents stating the wishes of individuals regarding healthcare in situations where they no longer are capable of giving personal informed consent.

Question 27

Based on religious beliefs, a patient’s husband has requested that only female caregivers provide care for his wife. What would be an appropriate intervention by the RN?

Answer 27

Change the assignment for the appropriate person to care for the wife (a female worker).

Question 28

During a health history which question should the RN ask the caregiver to determine how an illness is impacting a 3 year old? Select all that apply.

Answer 28

?

Question 29

Which patient response to “How do you respond to stress?” requires further investigation by the RN?

Answer 29

?

Question 30

What nursing intervention is used to obtain a health history for a patient who does not speak English?

Answer 30

Interpreter

Question 31

When asked about alcohol consumption/intake the patient states “I drink 6 bears a day.” What is the most appropriate response by the RN?

Answer 31

?

Question 32

What is the most appropriate question for the RN to ask a patient when assessing for abuse?

Answer 32

Are you afraid at home? Is someone hurting you?

Question 33

The patient medical record indicates a history of a partial removal of pancreas. Which area would require a focused assessment?

Answer 33

?

Question 34

When initiating the interview for the health history with a person in a wheelchair, what would be an appropriate approach for the RN to take?

Answer 34

Sit at eye level

Speak clearly

Question 35

What is the most appropriate response for the RN to conclude the history interview?

Answer 35

Is there anything else you would like us to know?

Question 36

A teenager is seeking health cares to help quiet “voices that are telling me to do bad things.” What should the RNs initial response be?

Answer 36

What bad things are the voices telling you to do?

Question 37

Which question should the RN ask the patient about current medications? Select all that apply

Answer 37

Which medications are you taking including herbal supplements and OTC meds.

Question 38

The RN is conducting a health history. The patient keeps asking “what?” before a sentence is completed. Which nursing action would be most appropriate?

Answer 38

Speak louder and more clearly

Question 39

Which statement obtained during the health history of a pregnant woman requires intervention by the RN?

Answer 39

?

Question 40

Which action taken by the RN best supports effective communication with an 8 year old?

Answer 40

?

Question 41

The patient acknowledges an allergy to Penicillin, which question should the RN ask next?

Answer 41

What happens (your reaction) when you take this medication?

Question 42

During the health history, the patient states “My spouse is in the waiting room.” What should be the RNs response?

Answer 42

?

Question 43

The RN assesses dry flaky skin, brittle nails, and a bright red tongue for a newly admitted patient. Based on the observation, which are requires more attention during the health history?

Answer 43

dehydration

Question 44

When taking a health history, which question should the RN ask to identify potential respiratory problems? Select all that apply

Answer 44

Are you a smoker

Question 45

Which statement by the patient admitted with a hip fracture requires further investigation by the RN?

Answer 45

?