health assessment dont fail bbg plsss i got u

Question 1

Which statement is true regarding the arterial system?a.Arteries are large-diameter vessels.
b.The arterial system is a high-pressure system.
c.The walls of arteries are thinner than those of the veins.
d.Arteries can greatly expand to accommodate a large blood volume increase.

Answer 1

b.The arterial system is a high-pressure system.

Question 2

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.
a.Ulnar
b.Radial
c.Brachial
d.Deep palmar

Answer 2

c. Brachial`

Question 3

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
a.Behind the knee
b.Over the lateral malleolus
c.In the groove behind the medial malleolus
d.Lateral to the extensor tendon of the great toe

Answer 3

d.Lateral to the extensor tendon of the great toe

Question 4

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting fora few minutes. The nurse recognizes that this description is most consistent with _______ the left leg.
a.Venous obstruction of
b.Claudication due to venous abnormalities in
c.Ischemia caused by a partial blockage of an artery supplying
d.Ischemia caused by the complete blockage of an artery supplying

Answer 4

c.Ischemia caused by a partial blockage of an artery supplying

Question 5

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
a. Intraluminal valves ensure unidirectional flow toward the heart.
b.Contracting skeletal muscles milk blood distally toward the veins.
c.High-pressure system of the heart helps facilitate venous return.
d.Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

Answer 5

a. Intraluminal valves ensure unidirectional flow toward the heart.

Question 6

Which vein(s) is(are) responsible for most of the venous return in the arm?
a.Deep
b.Ulnar
c.Subclavian
d.Superficial

Answer 6

d.Superficial

Question 7

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
a.Woman in her second month of pregnancy
b.Person who has been on bed rest for 4 days
c.Person with a 30-year, 1 pack per day smoking habit
d.Older adult taking anticoagulant medication

Answer 7

b.Person who has been on bed rest for 4 days

Question 8

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What happens to my circulation when this vein is removed?The nurse should reply:
a.Venous insufficiency is a common problem after this type of surgery.
b.Oh, you have lots of veins you wont even notice that it has been removed.
c.You will probably experience decreased circulation after the vein is removed.
d.This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition.

Answer 8

d.This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition.

Question 9

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
a.Lymph flow is propelled by the contraction of the heart.
b.The flow of lymph is slow, compared with that of the blood.
c.One of the functions of the lymph is to absorb lipids from the biliary tract.
d.Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the blood stream.

Answer 9

b.The flow of lymph is slow, compared with that of the blood.

Question 10

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?
a.Assess the patients abdomen, and notice any tenderness.
b.Carefully assess the cervical lymph nodes, and check for any enlargement.
c.Ask additional health history questions regarding any recent ear infections or sore throats.
d.Examine the patients lower arm and hand, and check for the presence of infection or lesions.

Answer 10

d.Examine the patients lower arm and hand, and check for the presence of infection or lesions.

Question 11

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
a.Hard and fixed cervical nodes
b.Enlarged and tender inguinal nodes
c.Bilateral enlargement of the popliteal nodes
d.Pellet-like nodes in the supraclavicular region

Answer 11

b.Enlarged and tender inguinal nodes

Question 12

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?a.Excessive swelling of the lymph nodes
b.Presence of palpable lymph nodes
c.No palpable nodes because of the immature immune system of a child
d.Fewer numbers and a smaller size of lymph nodes compared with those of an adult

Answer 12

b.Presence of palpable lymph nodes

Question 13

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?
a.Hormonal changes causing vasodilation and a resulting drop in blood pressure
b.Progressive atrophy of the intramuscular calf veins, causing venous insufficiency
c.Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
d.Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

Answer 13

c.Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

Question 14

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
a.Claudication.
b.Sore muscles.
c.Muscle cramps.
d.Venous insufficiency.

Answer 14

a.Claudication.

Question 15

A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed a sore on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:
a.Pain related to lymphatic abnormalities.
b.Problems related to arterial insufficiency.
c.Problems related to venous insufficiency.
d.Pain related to musculoskeletal abnormalities.

Answer 15

b.Problems related to arterial insufficiency.

Question 16

During an assessment, the nurse uses the profile sign to detect:
a.Pitting edema.
b.Early clubbing.
c.Symmetry of the fingers.
d.Insufficient capillary refill.

Answer 16

b.Early clubbing.

Question 17

The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
a.Ask the patient about a history of frostbite.
b.Suspect that the patient has venous insufficiency.
c.Consider this a delayed capillary refill time, and investigate further.
d.Consider this a normal capillary refill time that requires no further assessment.

Answer 17

c.Consider this a delayed capillary refill time, and investigate further.

Question 18

When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?
a.Document the finding.
b.Auscultate the site for a bruit.
c.Check for calf pain.
d.Check capillary refill in the toes.

Answer 18

b.Auscultate the site for a bruit.

Question 19

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patients skin is warm and capillary refill time is normal. Next, the nurse should:
a.Check for the presence of claudication.
b.Refer the individual for further evaluation.
c.Consider this finding as normal, and proceed with the peripheral vascular evaluation.
d.Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

Answer 19

c.Consider this finding as normal, and proceed with the peripheral vascular evaluation.

Question 20

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse.
a.Normal
b.Absent
c.Bounding
d.Weak, thready

Answer 20

c.Bounding

Question 21

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
a.To measure the rate of lymphatic drainage
b.To evaluate the adequacy of capillary patency before venous blood draws
c.To evaluate the adequacy of collateral circulation before cannulating the radial artery
d.To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

Answer 21

c.To evaluate the adequacy of collateral circulation before cannulating the radial artery

Question 22

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?a.Unilateral cool foot
b.Thin, shiny, atrophic skin
c.Pallor of the toes and cyanosis of the nail beds
d.Brownish discoloration to the skin of the lower leg

Answer 22

d.Brownish discoloration to the skin of the lower leg

Question 23

The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?
a.The patient is asked to assume a prone position.
b.The patient is asked to bend his or her knees to the side in a frog-like position.
c.The nurse firmly presses against the bone with the patient in a semi-Fowler position.
d.The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.

Answer 23

b.The patient is asked to bend his or her knees to the side in a frog-like position.

Question 24

When auscultating over a patients femoral arteries, the nurse notices the presence of a bruit on the left side.The nurse knows that bruits:
a.Are often associated with venous disease.
b.Occur in the presence of lymphadenopathy.
c.In the femoral arteries are caused by hypermetabolic states.
d.Occur with turbulent blood flow, indicating partial occlusion.

Answer 24

d.Occur with turbulent blood flow, indicating partial occlusion.

Question 25

How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
a.1+/0-4+
b.3+/0-4+
c.4+/0-4+
d.Brawny edema

Answer 25

a.1+/0-4+

Question 26

A patient has hard, non-pitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:
a.Non-pitting, hard edema occurs with lymphatic obstruction.
b.Alterations in arterial function will cause edema.
c.Phlebitis of a superficial vein will cause bilateral edema.
d.Long-standing arterial obstruction will cause pitting edema.

Answer 26

a.Non-pitting, hard edema occurs with lymphatic obstruction.

Question 27

When assessing a patients pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:
a.Alternans.
b.Bisferiens.
c.Bigeminus.
d.Paradoxus.

Answer 27

d.Paradoxus.

Question 28

During an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:
a.Significant elevational pallor.
b.Venous filling within 15 seconds.
c.No change in the coloration of the skin.
d.Color returning to the feet within 20 seconds of assuming a sitting position.

Answer 28

b.Venous filling within 15 seconds.

Question 29

During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel heavy in the calf and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?
a.Deep-vein thrombophlebitis
b.Varicose veins
c.Lymphedema
d.Raynaud phenomenon

Answer 29

b.Varicose veins

Question 30

During an assessment, the nurse notices that a patients left arm is swollen from the shoulder down to the fingers, with non-pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1year ago. The nurse suspects which problem?
a.Venous stasis
b.Lymphedema
c.Arteriosclerosis
d.Deep-vein thrombosis

Answer 30

b.Lymphedema

Question 31

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about theABI is true?a.Normal ABI indices are from 0.5 to 1.0.
b.Normal ankle pressure is slightly lower than the brachial pressure.
c.The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes.
d.An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.

Answer 31

d.An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.

Question 32

The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient?
a.Enlarged, warm, and tender nodes
b.Lymphadenopathy of the cervical nodes
c.Palpable firm, small, shotty, mobile, and non-tender lymph nodes
d.Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue

Answer 32

c.Palpable firm, small, shotty, mobile, and non-tender lymph nodes

Question 33

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?
a.Low humming sound
b.Regular lub, dub pattern
c.Swishing, whooshing sound
d.Steady, even, flowing sound

Answer 33

c.Swishing, whooshing sound

Question 34

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct?
a.Is easily palpable; pounds under the fingertips.
b.Has greater than normal force, then suddenly collapses.
c.Is hard to palpate, may fade in and out, and is easily obliterated by pressure.
d.Rhythm is regular, but force varies with alternating beats of large and small amplitude.

Answer 34

c.Is hard to palpate, may fade in and out, and is easily obliterated by pressure.

Question 35

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
a.Lymphedema.
b.Raynaud disease.
c.Deep-vein thrombosis.
d.Chronic arterial insufficiency.

Answer 35

b.Raynaud disease

Question 36

During a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that won’t heal. On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:
a.Varicosities.
b.Venous stasis ulcer.
c.Arterial ischemic ulcer.
d.Deep-vein thrombophlebitis.

Answer 36

c.Arterial ischemic ulcer.

Question 37

The nurse is reviewing an assessment of a patients peripheral pulses and notices that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse?
a.Bounding
b.Normal
c.Weak
d.Absent

Answer 37

b.Normal

Question 38

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply.
a.Intense, sharp pain, with the deep muscle tender to the touch
b.Aching, tired pain, with a feeling of fullness
c.Pain that is worse at the end of the day
d.Sudden onset
e.Warm, red, and swollen calf
f.Pain that is relieved with elevation of the leg

Answer 38

a.Intense, sharp pain, with the deep muscle tender to the touch
d.Sudden onset
e.Warm, red, and swollen calf

Question 39

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply.
a.Patient has a history of diabetes and cigarette smoking.
b.Skin of the patient is pale and cool.
c.His ankles have two small, weeping ulcers.
d.Patient works long hours sitting at a computer desk.
e.He states that the pain gets worse when walking.
f.Patient states that the pain is worse at the end of the day.

Answer 39

a.Patient has a history of diabetes and cigarette smoking.
b.Skin of the patient is pale and cool.
e.He states that the pain gets worse when walking.

Question 40

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
a.To provide an opportunity for interaction between the patient and the nurse
b.To provide a form for obtaining the patients biographic information
c.To document the normal and abnormal findings of a physical assessment
d.To provide a database of subjective information about the patients past and current health

Answer 40

d.To provide a database of subjective information about the patients past and current health

Question 41

When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient:
a.Has a history of drug abuse and therefore is not reliable.
b.Provided consistent information and therefore is reliable.
c.Smiled throughout interview and therefore is assumed reliable.
d.Would not answer questions concerning stress and therefore is not reliable.

Answer 41

b.Provided consistent information and therefore is reliable.

Question 42

59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care?
a.J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
b.J.M. came into the clinic complaining of having black stools for the past 24 hours.
c.J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked.
d.J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours.

Answer 42

d.J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours.

Question 43

4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response?
   a.Can you point to where it hurts?
   b.Well talk more about that later in the interview.
   c.What have you had to eat in the last 24 hours?
   d.Have you ever had any surgeries on your abdomen?

Answer 43

a.Can you point to where it hurts?

Question 44

A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the woman’s statement?
a.How does your family react to your pain?
b.The pain must be terrible. You probably pinched a nerve.
c.Ive had back pain myself, and it can be excruciating.
d.How would you say the pain affects your ability to do your daily activities?

Answer 44

d.How would you say the pain affects your ability to do your daily activities?

Question 45

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
a.Patient denies usual childhood illnesses.
b.Patient states he was a very healthy child.
c.Patient states his sister had measles, but he didnt.
d.Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Answer 45

d.Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Question 46

A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
a.P-6, B-4, (S)Ab-2
b.Grav 6, Term 4, (S)Ab-2, Living 4
c.Patient has had four living babies.
d.Patient has been pregnant six times.

Answer 46

b.Grav 6, Term 4, (S)Ab-2, Living 4

Question 47

A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information?
a.Are you allergic to any other drugs?
b.How often have you received penicillin?
c.Ill write your allergy on your chart so you wont receive any penicillin.
d.Describe what happens to you when you take penicillin.

Answer 47

d.Describe what happens to you when you take penicillin.

Question 48

The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
a.Emphysema.
b.Head trauma.
c.Mental illness.
d.Fractured bones.

Answer 48

c.Mental illness.

Question 49

The review of systems provides the nurse with:
a.Physical findings related to each system.
b.Information regarding health promotion practices.
c.An opportunity to teach the patient medical terms.
d.Information necessary for the nurse to diagnose the patients medical problem.

Answer 49

b.Information regarding health promotion practices.

Question 50

Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin?
a.Skin appears dry.
b.No lesions are obvious.
c.Patient denies any color change.
d.Lesion is noted on the lateral aspect of the right arm.

Answer 50

c.Patient denies any color change.

Question 51

The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
a.Do you perform testicular self-examinations?
b.Have you ever noticed any pain in your testicles?
c.Have you had any problems with passing urine?
d.Do you have any history of sexually transmitted diseases?

Answer 51

a.Do you perform testicular self-examinations?

Question 52

Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
a.I broke my right leg in a car accident 2 weeks ago.
b.The pain is decreasing, but I still need to take acetaminophen.
c.I check the color of my toes every evening just like I was taught.
d.Im able to transfer myself from the wheelchair to the bed without help.

Answer 52

d.Im able to transfer myself from the wheelchair to the bed without help.

Question 53

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate?
a.This has been a difficult year for you.
b.I dont know how anyone could handle that much stress in 1 year!
c.What did you do to cope with the loss of both your husband and mother?
d.That is a lot of stress; now lets go on to the next section of your history.

Answer 53

c.What did you do to cope with the loss of both your husband and mother?

Question 54

In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
a.This information is necessary to determine the patients reliability.
b.Alcohol can interact with all medications and can make some diseases worse.
c.The nurse needs to be able to teach the patient about the dangers of alcohol use.
d.This information is not necessary unless a drinking problem is obvious.

Answer 54

b.Alcohol can interact with all medications and can make some diseases worse.

Question 55

During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram?
a.List of diseases present in a persons near relatives
b.Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members
c.Drawing that depicts the patients family members up to five generations back
d.Description of the health of a persons children and grandchildren

Answer 55

b.Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members

Question 56

A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
a.Childs birth weight
b.Age at which he crawled
c.Whether the child has had the measles
d.Childs reactions to previous hospitalizations

Answer 56

d.Childs reactions to previous hospitalizations

Question 57

As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15months of age. What recommendation should the nurse make?
a.No further MMR immunizations are needed.
b.MMR vaccination needs to be repeated at 4 to 6 years of age.
c.MMR immunization needs to be repeated every 4 years until age 21 years.
d.A recommendation cannot be made until the physician is consulted.

Answer 57

b.MMR vaccination needs to be repeated at 4 to 6 years of age.

Question 58

In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the:
a.Last glaucoma examination.
b.Frequency of breast self-examinations.
c.Date of her last electrocardiogram.
d.Limitations related to her involvement in sports activities.

Answer 58

d.Limitations related to her involvement in sports activities.

Question 59

When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?a.Family history
b.Review of systems
c.Functional assessment
d.Reason for seeking care

Answer 59

c.Functional assessment

Question 60

The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
a.Obstetric history
b.Childhood illnesses
c.General health for the past 20 years
d.Current health promotion activities

Answer 60

d.Current health promotion activities

Question 61

The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation?
a.The questions asked are identical for all ages.
b.The interviewer will start incorporating different questions for patients 70 years of age and older.
c.Questions that are reflective of the normal effects of aging are added.
d.At this age, a review of systems is not necessary the focus should be on current problems.

Answer 61

c.Questions that are reflective of the normal effects of aging are added.

Question 62

A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be:
a.Can you tell me what they look like?
b.Dont worry about it. You are only taking two medications.
c.How long have you been taking each of the pills?d.Would you have a family member bring in your medications?

Answer 62

d.Would you have a family member bring in your medications?

Question 63

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke.Which of these questions would be most important to ask?
a.Do you wear glasses?
b.Are you able to dress yourself?
c.Do you have any thyroid problems?
d.How many times a day do you have a bowel movement?

Answer 63

b.Are you able to dress yourself?

Question 64

The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
a.The functional assessment assesses how the individual is coping with life at home.
b.It determines how children are meeting developmental milestones.
c.The functional assessment can identify any problems with memory the individual may be experiencing.
d.It helps determine how a person is managing day-to-day activities.

Answer 64

d.It helps determine how a person is managing day-to-day activities.

Question 65

The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom?
a.Chest pain
b.Clammy skin
c.Serum potassium level at 4.2 mEq/L
d.Body temperature of 100 F

Answer 65

a.Chest pain

Question 66

A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?
a.It is a sharp, burning pain in my stomach.
b.I also have the sweats and nausea when I feel this pain.
c.I think this pain is telling me that something bad is wrong with me.
d.This pain happens every time I sit down to use the computer.

Answer 66

d.This pain happens every time I sit down to use the computer.

Question 67

During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating?
a.The patient is an alcoholic.
b.The patient is annoyed at the questions.
c.The patient should be thoroughly examined for possible alcohol withdrawal symptoms.
d.The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

Answer 67

d.The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

Question 68

The nurse is incorporating a persons spiritual values into the health history. Which of these questions illustrates the community portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions?
a.Do you believe in God?
b.Are you a part of any religious or spiritual congregation?c.Do you consider yourself to be a religious or spiritual person?
d.How does your religious faith influence the way you think about your health?

Answer 68

b.Are you a part of any religious or spiritual congregation?

Question 69

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?
a.Please stay during the interview; you can answer for her if she does not know the answer.
b.It would help to interview the three of you together.
c.While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?
d.While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?

Answer 69

d.While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?

Question 70

The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history?
a.Why did you come to the United States?
b.When did you come to the United States and from what country?
c.What made you leave your native country?
d.Are you planning to return to your home?

Answer 70

b.When did you come to the United States and from what country?

Question 71

The nurse is assessing a patients headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply.
a.Where is the headache pain?
b.Did you have these headaches as a child?
c.On a scale of 1 to 10, how bad is the pain?
d.How often do the headaches occur?
e.What makes the headaches feel better?
f.Do you have any family history of headaches?

Answer 71

a.Where is the headache pain?
c.On a scale of 1 to 10, how bad is the pain?
d.How often do the headaches occur?
e.What makes the headaches feel better?

Question 72

The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.
a.How much junk food does your child eat?
b.How many teeth has he lost, and when did he lose them?
c.Is he able to tie his shoelaces?
d.Does he take a childrens vitamin?
e.Can he tell time?
f.Does he have any food allergies?

Answer 72

b.How many teeth has he lost, and when did he lose them?
c.Is he able to tie his shoelaces?
e.Can he tell time?

Question 73

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate?The woman is:
a.Excited about her pregnancy but nervous about the labor.
b.Exhibiting verbal and nonverbal behaviors that do not match.
c.Excited about her pregnancy, but her husband is not and this is upsetting to her.
d.Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.

Answer 73

b.Exhibiting verbal and nonverbal behaviors that do not match.

Question 74

Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional?
a.Well-adjusted adolescent who came in for a sports physical
b.Recovering alcoholic who came in for a basic physical examination
c.Man whose wife has just been diagnosed with lung cancer
d.Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him

Answer 74

c.Man whose wife has just been diagnosed with lung cancer

Question 75

The nurse makes which adjustment in the physical environment to promote the success of an interview?
a.Reduces noise by turning off televisions and radios
b.Reduces the distance between the interviewer and the patient to 2 feet or less
c.Provides a dim light that makes the room cozy and helps the patient relax
d.Arranges seating across a desk or table to allow the patient some personal space

Answer 75

a.Reduces noise by turning off televisions and radios

Question 76

In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
a.Note-taking may impede the nurses observation of the patients nonverbal behaviors.
b.Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
c.Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
d.Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.

Answer 76

a.Note-taking may impede the nurses observation of the patients nonverbal behaviors.

Question 77

The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process.
a.Summary
b.Closing
c.Body
d.Opening or introduction

Answer 77

d.Opening or introduction

Question 78

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?
a.Hello, Nancy, my name is Mrs. C.
b.Hello, Mrs. H., my name is Mrs. C. It sure is cold today!
c.Mrs. H., my name is Mrs. C. How are you?
d.Mrs. H., my name is Mrs. C. I’ll need to ask you a few questions about what happened.

Answer 78

d.Mrs. H., my name is Mrs. C. I’ll need to ask you a few questions about what happened.

Question 79

During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that.Which verbal skill is used with this statement?
a.Reflection
b.Facilitation
c.Direct question
d.Open-ended question

Answer 79

d.Open-ended question

Question 80

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data?
a.Mr. Y., at your age, surely you have been hospitalized before!
b.Mr. Y., I just need permission to get your medical records from County Medical.
c.Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?d.Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?

Answer 80

d.Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?

Question 81

In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be:
a.Empathy.
b.Reflection.
c.Facilitation.
d.Confrontation.

Answer 81

d.Confrontation.

Question 82

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior?
a.Be silent, and allow him to continue when he is ready.
b.Smile at him and say, Don’t worry about all of this. Im sure we can find out why you’re having these pains.
c.Lean back in the chair and ask, You are looking at me kind of funny; there isn’t anything wrong, is there?
d.Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time.

Answer 82

a.Be silent, and allow him to continue when he is ready.

Question 83

A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be:
a.Go on, Im listening.
b.Fits? Tell me what you mean by this.
c.Yes, it can be upsetting when a child has a fit.
d.Don’t be upset when he has a fit; every 2 year old has fits.

Answer 83

b.Fits? Tell me what you mean by this.

Question 84

A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy?a.You feel alone.
b.You cant believe he left you alone?
c.It must be so hard to face this all alone.
d.I would be angry, too; raising a child alone is no picnic.

Answer 84

c.It must be so hard to face this all alone.

Question 85

A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
a.Mr. K., I know that you are lying.
b.Mr. K., come on, tell me how much you smoke.
c.Mr. K., I didn’t realize your wife had died. It must be difficult for you at this time. Please tell me more about that.
d.Mr. K., you have said that you don’t smoke, but I see that you have an open pack of cigarettes in your pocket.

Answer 85

d.Mr. K., you have said that you don’t smoke, but I see that you have an open pack of cigarettes in your pocket.

Question 86

The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to:
a.Apologize, because using interpretation can be demeaning for the patient.
b.Allow time for the patient to confirm or correct the inference.
c.Continue with the interview as though nothing has happened.
d.Immediately restate the nurses conclusion on the basis of the patients nonverbal response.

Answer 86

b.Allow time for the patient to confirm or correct the inference.

Question 87

During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be:
a.You are going to leave him?
b.If you are afraid for your children, then why cant you leave?
c.It sounds as if you might be afraid of how your husband will respond.
d.It sounds as though you have made your decision. I think it is a good one.

Answer 87

c.It sounds as if you might be afraid of how your husband will respond.

Question 88

A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a:
a.Therapeutic response. By sharing something personal, the nurse gives hope to this woman.
b.Non-therapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears.
c.Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman.
d.Non-therapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.

Answer 88

b.Non-therapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears.

Question 89

During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesn’t understand how hard Ive tried. I just don’t know the best way to do it. What should I do? The nurses most appropriate response in this case would be:
a.Id quit if I were you. The doctor really knows what he is talking about.
b.Would you like some information about the different ways a person can quit smoking?
c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel.
d.Why are you confused? Didn’t the doctor give you the information about the smoking cessation program we offer?

Answer 89

b.Would you like some information about the different ways a person can quit smoking?

Question 90

As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner:
a.You’re afraid you might lose your breast?
b.No, Im not sure what you are talking about.
c.Ill wait here until you get yourself under control, and then we can talk.
d.I can see that you are very upset. Perhaps we should discuss this later.

Answer 90

a.You’re afraid you might lose your breast?

Question 91

A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You don’t smoke, drink, or take drugs, do you? This question is an example of:
a.Talking too much.
b.Using confrontation.
c.Using biased or leading questions.
d.Using blunt language to deal with distasteful topics.

Answer 91

c.Using biased or leading questions.

Question 92

When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
a.Ask someone who knows the patient well to help interpret this discrepancy.
b.Focus on the patients verbal message, and try to ignore the nonverbal behaviors.
c.Try to integrate the verbal and nonverbal messages and then interpret them as an average.
d.Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

Answer 92

d.Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

Question 93

During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:
a.Simply changing positions.
b.More comfortable in this position.
c.Tired and needs a break from the interview.
d.Uncomfortable talking about his sons treatment.

Answer 93

d.Uncomfortable talking about his sons treatment.

Question 94

A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?
a.Tickle the toddler, and get her to laugh.
b.Stoop down to her level, and ask her about the toy she is holding.
c.Continue to ignore her until it is time for the physical examination.
d.Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.

Answer 94

b.Stoop down to her level, and ask her about the toy she is holding.

Question 95

During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the child’s full cooperation?
a.Tell the child that the blood pressure cuff is going to give her arm a big hug.
b.Tell the child that the blood pressure cuff is asleep and cannot wake up.
c.Give the blood pressure cuff a name and refer to it by this name during the assessment.
d.Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

Answer 95

d.Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

Question 96

A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him?
a.Use periods of silence to communicate respect for him.
b.Be totally honest with him, even if the information is unpleasant.
c.Tell him that everything that is discussed will be kept totally confidential.
d.Use slang language when possible to help him open up.

Answer 96

b.Be totally honest with him, even if the information is unpleasant.

Question 97

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this?
a.An aged person has a longer story to tell.
b.An aged person is usually lonely and likes to have someone with whom to talk.
c.Aged persons lose much of their mental abilities and require longer time to complete an interview.
d.As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said.

Answer 97

a.An aged person has a longer story to tell.

Question 98

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?
a.Determine the communication method he prefers.
b.Avoid using facial and hand gestures because most hearing-impaired people find this degrading.
c.Request a sign language interpreter before meeting with him to help facilitate the communication.
d.Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.

Answer 98

a.Determine the communication method he prefers.

Question 99

During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be:
a.Im so sorry for making you cry!
b.I can see that you are sad remembering this. It is all right to cry.
c.Why don’t I step out for a few minutes until you’re feeling better?
d.I can see that you feel sad about this; why don’t we talk about something e

Answer 99

b.I can see that you are sad remembering this. It is all right to cry.

Question 100

A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next?
a.The nurse should try to relax; these behaviors are culturally appropriate for this person.
b.The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview.
c.These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors.
d.The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.

Answer 100

a.The nurse should try to relax; these behaviors are culturally appropriate for this person.

Question 101

A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation?
a.The woman is nervous and embarrassed.
b.She has something to hide and is ashamed.
c.The woman is showing inconsistent verbal and nonverbal behaviors.
d.She is showing that she is carefully listening to what the nurse is saying.

Answer 101

d.She is showing that she is carefully listening to what the nurse is saying.

Question 102

The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation?
a.Do you take medicine?
b.Do you sterilize the bottles?
c.Do you have nausea and vomiting?
d.You have been taking your medicine, haven’t you?

Answer 102

a.Do you take medicine?

Question 103

A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems.Which question or statement by the nurse is most appropriate when beginning the interview?
a.How is your family?
b.How is your job?
c.Tell me about your hypertension.
d.How has your health been since your last visit?

Answer 103

d.How has your health been since your last visit?

Question 104

The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment?
a.This comment is inappropriate because it shows the nurses bias.
b.This comment is appropriate because members of the health care team are experts in their area of patient care.
c.This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation.
d.Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

Answer 104

c.This type of comment promotes dependency and inferiority on the part of the patient and is best

Question 105

33. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
    a.Trained interpreter
    b.Male family member
    c.Female family member
    d.Volunteer college student from the foreign language studies department

Answer 105

a.Trained interpreter

Question 106

During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why haven’t you taken your insulin? Which statement is an appropriate evaluation of this question?a.This question may place the patient on the defensive.
b.This question is an innocent search for information.
c.Discussing his behavior with his wife would have been better.
d.A direct question is the best way to discover the reasons for his behavior.

Answer 106

a.This question may place the patient on the defensive.

Question 107

The nurse is nearing the end of an interview. Which statement is appropriate at this time?
a.Did we forget something?
b.Is there anything else you would like to mention?
c.I need to go on to the next patient. I’ll be back.
d.While Im here, let’s talk about your upcoming surgery.

Answer 107

b.Is there anything else you would like to mention?

Question 108

During the interview portion of data collection, the nurse collects __________ data.
a.Physical
b.Historical
c.Objective
d.Subjective

Answer 108

d.Subjective

Question 109

During an interview, the nurse would expect that most of the interview will take place at what distance?
a.Intimate zone
b.Personal distance
c.Social distance
d.Public distance

Answer 109

c.Social distance

Question 110

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be:
a.Stop that immediately!
b.Oh, you are too funny. Let’s keep going with the interview.
c.Do you really think I would be interested?
d.It makes me uncomfortable when you talk that way. Please stop.

Answer 110

d.It makes me uncomfortable when you talk that way. Please stop.

Question 111

The nurse is conducting an interview. Which of these statements is true regarding open-ended questions?Select all that apply.
a.Open-ended questions elicit cold facts.
b.They allow for self-expression.
c.Open-ended questions build and enhance rapport.
d.They leave interactions neutral.
e.Open-ended questions call for short one- to two-word answers.
f.They are used when narrative information is needed.

Answer 111

b.They allow for self-expression.
c.Open-ended questions build and enhance rapport.
f.They are used when narrative information is needed.

Question 112

The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? Select all that apply.
a.Collect the patients data in a direct, face-to-face manner.
b.Enter all the data as the patient states them.
c.Ask the patient to wait as the nurse enters the data.
d.Type the data into the computer after the narrative is fully explored.
e.Allow the patient to see the monitor during typing.

Answer 112

a.Collect the patients data in a direct, face-to-face manner.
d.Type the data into the computer after the narrative is fully explored.
e.Allow the patient to see the monitor during typing.

Question 113

The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is:
a.Genetically determined on the basis of racial background.
b.Learned through language acquisition and socialization.
c.A nonspecific phenomenon and is adaptive but unnecessary.
d.Biologically determined on the basis of physical characteristics.

Answer 113

b.Learned through language acquisition and socialization.

Question 114

During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics?a.Cultures are static and unchanging, despite changes around them.
b.Cultures are never specific, which makes them hard to identify.
c.Culture is most clearly reflected in a persons language and behavior.
d.Culture adapts to specific environmental factors and available natural resources

Answer 114

d.Culture adapts to specific environmental factors and available natural resources

Question 115

During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term?
a.Mores
b.Norms
c.Culture
d.Social learning

Answer 115

c.Culture

Question 116

When discussing the use of the term subculture, the nurse recognizes that it is best described as:
a.Fitting as many people into the majority culture as possible.
b.Defining small groups of people who do not want to be identified with the larger culture.
c.Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations.
d.Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.

Answer 116

d.Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.

Question 117

When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is:
a.Hispanic.
b.Black.
c.Asian.
d.American Indian.

Answer 117

a.Hispanic.

Question 118

During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?
a.Ask the patient about the item and its significance.
b.Ask the patient to lock the item with other valuables in the hospitals safe.
c.Tell the patient that a family member should take valuables home.
d.No action is necessary.

Answer 118

a.Ask the patient about the item and its significance.

Question 119

The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver:
a.Is able to speak the patients native language.
b.Possesses some basic knowledge of the patients cultural background.
c.Applies the proper background knowledge of a patients cultural background to provide the best possible health care.
d.Understands and attends to the total context of the patients situation.

Answer 119

d.Understands and attends to the total context of the patients situation.

Question 120

The nurse recognizes that an example of a person who is heritage consistent would be a:
a.Woman who has adapted her clothing to the clothing style of her new country.
b.Woman who follows the traditions that her mother followed regarding meals.
c.Man who is not sure of his ancestors country of origin.
d.Child who is not able to speak his parents native language.

Answer 120

b.Woman who follows the traditions that her mother followed regarding meals.

Question 121

After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
a.Ethnicity is dynamic and ever changing.
b.Ethnicity is the belief in a higher power.
c.Ethnicity pertains to a social group within the social system that claims shared values and traditions.
d.Ethnicity is learned from birth through the processes of language acquisition and socialization.

Answer 121

c.Ethnicity pertains to a social group within the social system that claims shared values and traditions.

Question 122

The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality?
a.Belief in and the worship of God or gods
b.Attendance at a specific church or place of worship
c.Personal effort made to find purpose and meaning in life
d.Being closely tied to ones ethnic background

Answer 122

c.Personal effort made to find purpose and meaning in life

Question 123

A woman who has lived in the United States for a year after moving from Europe has learned to speakEnglish and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?
a.Assimilation
b.Heritage consistency
c.Biculturalism
d.Acculturation

Answer 123

a.Assimilation

Question 124

The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?
a.What is your religion?
b.Do you mostly participate in the religious traditions of your family?
c.Do you smoke?
d.Do you have a history of heart disease?

Answer 124

b.Do you mostly participate in the religious traditions of your family?

Question 125

In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans:
a.Have less efficient immune systems and are often ill.
b.Consider these symptoms part of normal living, not symptoms of ill health.
c.Come from Mexico, and coughing is normal and healthy there.
d.Are usually in a lower socioeconomic group and are more likely to be sick.

Answer 125

b.Consider these symptoms part of normal living, not symptoms of ill health.

Question 126

The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?a.Holistic
b.Biomedical
c.Naturalistic
d.Magicoreligious

Answer 126

b.Biomedical

Question 127

An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with:
a.Foods that are hot or yang.
b.Readings and Eastern medicine meditations.
c.High doses of medicines believed to be cold.
d.No treatment is tried because diarrhea is an expected part of life.

Answer 127

a.Foods that are hot or yang.

Question 128

Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao.Which statement most accurately reflects health in an Asian with this belief?a.A person is able to work and produce.
b.A person is happy, stable, and feels good.
c.All aspects of the person are in perfect balance.
d.A person is able to care for others and function socially.

Answer 128

c.All aspects of the person are in perfect balance.

Question 129

Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory?
a.Naturalistic
b.Biomedical
c.Reductionist
d.Magicoreligious

Answer 129

a.Naturalistic

Question 130

An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by:
a.Germs and viruses.
b.Supernatural forces.
c.Eating imbalanced foods.
d.An imbalance within his or her spiritual nature.

Answer 130

b.Supernatural forces.

Question 131

If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she:
a.Will comply with the treatment prescribed.
b.Has obviously given up her belief in naturalistic causes of disease.
c.May also be seeking the assistance of a shaman or medicine man.
d.Will need extra help in dealing with her illness and may be experiencing a crisis of faith.

Answer 131

c.May also be seeking the assistance of a shaman or medicine man.

Question 132

An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would:
a.Contact the hospital administrator about the best course of action.
b.Automatically get a curandero for her, because requesting one herself is not culturally appropriate.
c.Further assess the patients cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.
d.Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families

Answer 132

c.Further assess the patients cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.

Question 133

A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action?
a.The nurse should focus on performing a full cardiac assessment.
b.The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer.
c.This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician.
d.It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms.

Answer 133

d.It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms.

Question 134

Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain?
a.Nurses attitudes toward their patients pain are unrelated to their own experiences with pain.
b.Nurses need to recognize that many cultures practice silent suffering as a response to pain.
c.A nurses area of clinical practice will most likely determine his or her assessment of a patients pain.
d.A nurses years of clinical experience and current position are strong indicators of his or her response of patient pain

Answer 134

b.Nurses need to recognize that many cultures practice silent suffering as a response to pain.

Question 135

The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?
a.All patients will behave the same way when in pain.
b.Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.
c.Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined.
d.A patients expression of pain is largely dependent on the amount of tissue injury associated with the pain.

Answer 135

b.Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

Question 136

During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality:
a.Is a personal search to discover a supreme being.
b.Is an organized system of beliefs concerning the cause, nature, and purpose of the universe.
c.Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife.
d.Arises out of each persons unique life experience and his or her personal effort to find purpose in life.

Answer 136

d.Arises out of each persons unique life experience and his or her personal effort to find purpose in life.

Question 137

The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:
a.Children have spiritual needs that are influenced by their stages of development.
b.Children have spiritual needs that are direct reflections of what is occurring in their homes.
c.Religious beliefs rarely affect the parents perceptions of the illness.
d.Parents are often the decision makers, and they have no knowledge of their children’s spiritual needs.

Answer 137

a.Children have spiritual needs that are influenced by their stages of development.

Question 138

A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman’s sister until they can get a home of their own. When company arrives to visit with the woman’s sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing:
a.Culture shock.
b.Cultural taboos.
c.Cultural unfamiliarity.
d.Culture disorientation.

Answer 138

a.Culture shock.

Question 139

After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is:
a.Not recognized as valuable by most health care providers.
b.Usually ineffective and may delay more effective treatment.
c.Always less expensive than biomedical alternatives.
d.Influenced by the accessibility of over-the-counter medicines.

Answer 139

d.Influenced by the accessibility of over-the-counter medicines.

Question 140

The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?
a.The causation of illness is based on supernatural forces that influence the humors of the body.
b.Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body.
c.The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual.
d.The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.

Answer 140

d.The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.

Question 141

In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition?a.Patient with diabetes and renal failure
b.Teenager with an abscessed tooth
c.Child with symptoms of itching and a rash
d.Older man with gastrointestinal discomfort

Answer 141

d.Older man with gastrointestinal discomfort

Question 142

When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient?
a.Are you of the Christian faith?
b.Do you want to see a medicine man?
c.How often do you seek help from medical providers?d.What cultural or spiritual beliefs are important to you?

Answer 142

d.What cultural or spiritual beliefs are important to you?

Question 143

During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
a.Believing that illness is a punishment of sin
b.Trying prayer before seeking medical help
c.Refusing to accept blood products as part of treatment
d.Stating that a child’s birth defect is the result of the parents sins concept of a cultural taboo?

Answer 143

c.Refusing to accept blood products as part of treatment

Question 144

The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of:
a.Family.
b.Cultures.
c.Spirituality.
d.Subcultures.

Answer 144

d.Subcultures.

Question 145

The nurse is reviewing concepts related to ones heritage and beliefs. The belief in divine or super human power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as:
a.Culture.
b.Religion.
c.Ethnicity.
d.Spirituality.

Answer 145

b.Religion.

Question 146

When planning a cultural assessment, the nurse should include which component?
a.Family history
b.Chief complaint
c.Medical history
d.Health-related beliefs

Answer 146

d.Health-related beliefs

Question 147

Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is:
a.Being rewarded for good behavior.
b.The balance of the body and spirit.
c.Maintained by wearing jade amulets.
d.Being in harmony with nature.

Answer 147

d.Being in harmony with nature.

Question 148

The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply.
a.Examine the patient within the context of ones own cultural health and illness practices.
b.Select questions that are not complex.
c.Ask questions rapidly.
d.Touch patients within the cultural boundaries of their heritage.
e.Pace questions throughout the physical examination.

Answer 148

b.Select questions that are not complex.
d.Touch patients within the cultural boundaries of their heritage.
e.Pace questions throughout the physical examination.

Question 149

The nurse is asking questions about a patients health beliefs. Which questions are appropriate? Select all that apply.
a.What is your definition of health?
b.Does your family have a history of cancer?
c.How do you describe illness?
d.What did your mother do to keep you from getting sick?e.Have you ever had any surgeries?
f.How do you keep yourself healthy?

Answer 149

a.What is your definition of health?
c.How do you describe illness?
d.What did your mother do to keep you from getting sick?
f.How do you keep yourself healthy?