NUR302-Practice Quiz

Question 1

A pregnant woman states, “I just know labor will be so painful that I won’t 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 the nurse’s response?
Therapeutic response. By sharing something personal, the nurse gives hope to this woman.

Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears.

Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman.

Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.

Answer 1

Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears.

By saying “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” the nurse is providing false assurance or reassurance. This may give the nurse a false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually trivializes her anxiety, and effectively denies any further talk of it, thus, closing off communication. The nurse’s statement, “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” is not therapeutic because it trivializes the patient’s anxiety about pain, and effectively denies any further talk of it, thus, closing off communication.

Question 2

A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of assessment data is this?
Objective
Reflective
 Subjective
 Introspective

Answer 2

Subjective

Subjective data is what the person says about him or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data.

Question 3

The nurse is assessing a patient’s pain. What should the nurse know is the most reliable indicator of pain?
Subjective report
Physical examination
Patient’s vital signs
Results of a computerized axial tomographic scan

Answer 3

Subjective report

The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot exclusively base the diagnosis of pain on physical assessment findings. Although the physical examination findings, vital signs, and CAT scan findings can lend support, the clinician cannot exclusively base the diagnosis of pain on those findings. The patient’s subjective report is the most reliable indicator of pain.

Question 4

The nurse recognizes which of these people is at greatest risk for undernutrition?
  30-year-old man
  50-year-old woman
  5-month-old infant
  20-year-old college student

Answer 4

5-month-old infant

Vulnerable groups for undernutrition are infants, children, pregnant women, recent immigrants, people with low incomes, hospitalized people, and aging adults.

Question 5

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?
  Palpation
  Inspection
  Percussion
  Auscultation

Answer 5

Palpation

Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain.

Question 6

When assessing the quality of a patient’s pain, the nurse should ask which question?
  “When did the pain start?”
  “Is the pain a stabbing pain?”
  “Is it a sharp pain or dull pain?”
  “What does your pain feel like?”

Answer 6

“What does your pain feel like?”

To assess the quality of a person’s pain, the patient is asked to describe the pain in his or her own words. Asking when the pain started does not assess the quality of pain. To assess the quality of a person’s pain, the patient is asked to describe the pain in his or her own words, not providing descriptions of types of pain for the patient to confirm or deny.

Question 7

The nurse has collected the following information on a patient: palpated blood pressure–180 mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse–60 beats per minute; radial pulse–70 beats per minute. What is the patient’s pulse pressure?

10
70
80
100

Answer 7

70

Pulse pressure is the difference between systolic and diastolic blood pressure (170 – 100 = 70) and reflects the stroke volume.

Question 8

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child’s respirations?
Respirations should be counted for 1 full minute if the nurse suspects an abnormality.
Child’s pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
Child’s respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
Patient’s respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.

Answer 8

Respirations should be counted for 1 full minute if the nurse suspects an abnormality.

Respirations are counted for 1 full minute if an abnormality is suspected. The other responses are not correct actions. The pulse and respirations should not be counted at the same time. Instead, the nurse should maintain the position as if taking the radial pulse, but unobtrusively count the respirations. Respirations should be counted for 30 seconds if no abnormality, not 5 minutes or 15 seconds. If an abnormality is suspected, the nurse should count respirations for 1 full minute.

Question 9

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?

Palpation
Inspection
Percussion
Auscultation

Answer 9

Palpation

Palpation uses the sense of touch to assess the patient for the factors in the question (texture, temperature, moisture, and swelling). Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.

Question 10

The nurse is evaluating a patient’s pain. Which is an example of acute pain?
  Fibromyalgia
  Arthritic pain
  Kidney stones
  Lower back pain

Answer 10

Kidney stones

Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals, such as with surgery, trauma, and kidney stones. The other conditions are examples of chronic pain in which the pain continues for 6 months or longer and does not stop when the injury heals. Fibromyalgia, arthritic pain, and lower back pain are examples of nonmalignant chronic pain (pain that continues for 6 months or longer and does not stop when the injury heals), not acute pain.

Question 11

The nurse should measure rectal temperatures in which of these patients?
Older adult
Comatose adult
School-age child
Patient receiving oxygen by nasal cannula

Answer 11

Comatose adult

Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused people, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.

Question 12

When assessing the intensity of a patient’s pain, which question by the nurse is appropriate?
“What does your pain feel like?”
“How much pain do you have now?”
“How does pain limit your activities?”
“What makes your pain better or worse?”

Answer 12

“How much pain do you have now?”

Asking the patient “how much pain do you have?” is an assessment of the intensity of a patient’s pain; various intensity scales can be used. Asking “what does your pain feel like” assesses the quality of pain. Asking whether pain limits one’s activities assesses the degree of impairment and quality of life. Asking what makes one’s pain better or worse assesses alleviating or aggravating factors. Asking “what does your pain feel like” assesses the quality of pain. Asking whether pain limits one’s activities assesses the degree of impairment and quality of life. Asking what makes one’s pain better or worse assesses alleviating or aggravating factors. To assess the intensity of pain, the nurse should ask the patient “how much pain do you have?” This is an assessment of the intensity of a patient’s pain; various intensity scales can be used.

Question 13

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
The pulse is more difficult to palpate because of the stiffness of the blood vessels.
An increased respiratory rate and a shallower inspiratory phase are expected findings.
A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures.
Changes in the body’s temperature regulatory mechanism leave the older person more likely to develop a fever.

Answer 13

An increased respiratory rate and a shallower inspiratory phase are expected findings.

Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate. An increase in the rigidity of the arterial walls actually makes the pulse easier to palpate. Pulse pressure is widened in older adults, and changes in the body temperature regulatory mechanism leave the older person less likely to have fever but at a greater risk for hypothermia. Pulse pressure is widened, rather than decreased, in older adults, and changes in the body temperature regulatory mechanism leave the older person less likely to have fever but at a greater risk for hypothermia. As people age there is a decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate.

Question 14

Which of these statements is true regarding the use of Standard Precautions in the health care setting?
Standard Precautions apply to all body fluids, including sweat.
An alcohol-based hand rub should be used if hands are visibly dirty.
Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

Answer 14

Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.

Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.

Question 15

The nurse is performing a general survey of a patient. Which finding is considered normal?

Body mass index (BMI) of 20
When standing, the patient’s base is narrow.
The patient appears older than his stated age.
Arm span (fingertip to fingertip) is greater than the height

Answer 15

Body mass index (BMI) of 20

A body mass index (BMI) of 20 is normal. A normal BMI is 19-24. When standing, a patient’s base should be wide, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism. When performing the general survey, the patient’s arm span (fingertip to fingertip) should equal the patient’s height. An arm span that is greater than the person’s height may indicate Marfan syndrome. When standing, a patient’s base should be wide, not narrow, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism.

Question 16

he nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group?
Explain the procedures in detail to alleviate the child’s anxiety.
Give the child feedback and reassurance during the examination.
Do not ask the child to remove his or her clothes because children at this age are usually very private.
Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen.

Answer 16

Give the child feedback and reassurance during the examination.

With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler. This is a preschool-aged child so the nurse should not explain procedures in detail as that will likely make the child anxious. Children at this age are usually willing to undress and should do so as needed for a thorough examination. An examination of the head should be performed last, not first. During the examination of a preschool-aged child, needed feedback and reassurance should be given to the child and short, simple explanations should be used.

Question 17

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. What type of assessment data is this?

Objective
Reflective
Subjective
Introspective

Answer 17

Objective

Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data.

Question 18

The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?
Yield a falsely low blood pressure
Yield a falsely high blood pressure
Be the same, regardless of cuff size
Vary as a result of the technique of the person performing the assessment

Answer 18

Yield a falsely high blood pressure

Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery.

Question 19

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?

EBP relies on tradition for support of best practices.
EBP is simply the use of best practice techniques for the treatment of patients.
EBP emphasizes the use of best evidence with the clinician’s experience.
EBP does not consider the patient’s own preferences as important.

Answer 19

EBP emphasizes the use of best evidence with the clinician’s experience.

EBP is a systematic approach to practice that emphasizes the use of research evidence in combination with the clinician’s expertise and clinical knowledge (physical assessment), as well as patient values and preferences, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists.

Question 20

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
Used to listen for high-pitched sounds
Used to listen for low-pitched sounds
Should be lightly held against the person’s skin to block out low-pitched sounds
Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs

Answer 20

Used to listen for high-pitched sounds

The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held against the person’s skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs.

Question 21

Which of these specific measurements is the best index of a child’s general health?
  Body mass index
  Height and weight
  Head circumference
  Chest circumference

Answer 21

Height and weight

Physical growth, measured by height and weight, is the best index of a child’s general health.

Question 22

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action?
Perform a complete mental status examination.
Refer him to a psychometrician.
Plan to integrate the mental status examination into the history and physical examination.
Reassure his wife that memory loss after a physical shock is normal and will soon subside.

Answer 22

Perform a complete mental status examination.

Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

Question 23

When performing a physical assessment, what technique should the nurse always perform first?
  Palpation
  Inspection
  Percussion
  Auscultation

Answer 23

Inspection

The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system always begins with inspection. A focused inspection takes time and yields a surprising amount of information.

Question 24

A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” Which is the best reply by the nurse?
“The numbers are within the normal range and are nothing to worry about.”
“The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”
“The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”
“The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.”

Answer 24

“The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”

The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient’s question and use terms he can understand. The nurse should answer the patient’s question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume.

Question 25

The nurse is performing a general survey. Which action is a component of the general survey?

Observing the patient’s body stature and nutritional status
Interpreting the subjective information the patient has reported
Measuring the patient’s temperature, pulse, respiration, and blood pressure
Observing specific body systems while performing the physical assessment

Answer 25

Observing the patient’s body stature and nutritional status

The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior. Interpreting subjective data is not part of the general survey. Measuring the patient’s vital signs (temperature, pulse, respirations, and blood pressure) and observing specific body systems while performing a physical assessment are part of the physical examination, not the general survey.

Question 26

An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient’s gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition?
  Rickets
  Vitamin A deficiency
  Linoleic-acid deficiency
  Vitamin C deficiency

Answer 26

Vitamin C deficiency

Vitamin C deficiency causes swollen, ulcerated, and bleeding gums, known as scorbutic gums. Rickets is a condition r/t vitamin D and calcium deficiencies in infants and children. Vitamin A deficiency causes Bitot spots and visual problems. Linoleic-acid deficiency causes eczematous skin.

Question 27

For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. Which activity should the initial nutritional screening include?
Anthropometric measures
Calorie count of nutrients
Complete physical examination
Measurement of weight and weight history

Answer 27

Measurement of weight and weight history

Parameters used for nutrition screening typically include weight and height history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. The other responses reflect a more in-depth assessment rather than a screening. Anthropometric measures, calorie count of nutrients, and a complete physical examination are all a part of a more in-depth nutritional assessment than an initial nutrition screening. Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data.

Question 28

In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find?
  Increase in hair growth
  Weight 10% to 20% over ideal
  Sore, inflamed buccal cavity
  Inadequate nutrient or food intake

Answer 28

Inadequate nutrient or food intake

Dysphagia, or impaired swallowing, interferes with adequate nutrient or food intake. Since dysphagia, or impaired swallowing, interferes with adequate nutrient intake, the nurse would not expect increased hair growth or being overweight. Sore, inflamed buccal cavity is also not an expected finding for a patient with dysphagia. The correct answer is inadequate nutrient or food intake as difficulty swallowing would make it difficult to get adequate oral nutrition.

Question 29

The nurse is counting an infant’s respirations. Which technique is correct?
Watching the chest rise and fall
Observing the movement of the abdomen
Placing a hand across the infant’s chest
Using a stethoscope to listen to the breath sounds

Answer 29

Observing the movement of the abdomen

Watching the abdomen for movement is the correct technique because the infant’s respirations are normally more diaphragmatic than thoracic. The other responses do not reflect correct techniques. To count the respirations of an infant the nurse should not observe or place a hand on the chest because infants’ respirations are more diaphragmatic than thoracic. The nurse should also not listen with a stethoscope to count respirations because that will influence the infant’s breathing. Instead, watching the abdomen for movement is the correct technique to count an infant’s respirations because the infant’s respirations are normally more diaphragmatic than thoracic.

Question 30

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?
Ask the patient about the item and its significance.
Ask the patient to lock the item with other valuables in the hospital’s safe.
Tell the patient that a family member should take valuables home.
No action is necessary.

Answer 30

Ask the patient about the item and its significance.

The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from “evil spirits.” When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet’s meaning to the patient. Asking the patient to lock the item with other valuables in the hospital’s safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient’s cultural health practices

Question 31

While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur?
Electrocardiogram
Bell of the stethoscope
Diaphragm of the stethoscope
Palpation with the nurse’s palm of the hand

Answer 31

Bell of the stethoscope

An electrocardiogram and palpation are not used to assess murmurs. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds, not murmurs. The bell of the stethoscope is best for soft, low-pitched sounds such as murmurs, or extra heart sounds.

Question 32

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Breathing, pain, and sleep
Breathing, sleep, and pain
Sleep, breathing, and pain
Sleep, pain, and breathing

Answer 32

Breathing, pain, and sleep

First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems.

Question 33

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.” Based on this question, the nurse is at which phase of the interview process?
  Summary
  Closing
  Working
  Opening or introduction

Answer 33

Opening or introduction

When gathering a complete history, the nurse should give the reason for the interview during the opening or introduction phase of the interview, not during or at the end of the interview.

Question 34

While measuring a patient’s blood pressure, the nurse should recall that which is a factor that influences a patient’s blood pressure?
  Pulse rate
  Pulse pressure
  Vascular output
  Peripheral vascular resistance

Answer 34

Peripheral vascular resistance

The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls.

Question 35

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, “It hurts so bad.” Which pain assessment tool would be the best choice when assessing this child’s pain?
  Descriptor scale
  Numeric rating scale
  Brief pain inventory
  Faces Pain Scale—Revised (FPS-R)

Answer 35

Faces Pain Scale—Revised (FPS-R)

Rating scales can be introduced at the age of 4 or 5 years. The FPS-R is designed for use by children and asks the child to choose a face that shows “how much hurt (or pain) you have now.” Young children should not be asked to rate pain by using numbers. A 4-year-old should not be asked to use a descriptor scale, numeric rating scale, or brief pain inventory as they do not have the ability to accurately describe or rate pain intensity on a numerical scale. Although rating scales can be introduced at the age of 4 or 5 years, the FPS-R scale should be used. The FPS-R scale is designed for use by children and asks the child to choose a face that shows “how much hurt (or pain) you have now.”

Question 36

The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of a culturally competent caregiver?

Able to speak the patient’s native language
Possesses some basic knowledge of the patient’s cultural background
Applies the underlying background knowledge of a patient’s culture to provide the best possible health care
Understands and attends to the total context of the patient’s situation

Answer 36

Understands and attends to the total context of the patient’s situation

Culturally competent implies that the caregiver understands and attends to the total context of the individual’s situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. It does not require the caregiver to speak the patient’s native language. Speaking the patient’s native language is not required for culturally competency. Possessing some basic knowledge of the patient’s cultural background describes cultural sensitivity. Applying underlying background knowledge of a patient’s culture to provide the best possible health care describes being culturally appropriate.

Question 37

When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure?
  200/92
  200/100
  100/200/92
  200/100/92

Answer 37

200/92

In adults, the last audible sound best indicates the diastolic pressure. When a variance is greater than 10 to 12 mm Hg between phases IV and V, both phases should be recorded along with the systolic reading (e.g., 142/98/80).

Question 38

The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next?
Auscultate over the area with a fetoscope.
Use a goniometer to measure the pulsations.
Use a Doppler device to check for pulsations over the area.
Check for the presence of pulsations with a stethoscope.

Answer 38

Use a Doppler device to check for pulsations over the area.

Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. When unable to palpate a pulse, a Doppler device should be used.

Question 39

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?
  Reflection
  Facilitation
  Direct question
  Open-ended question

Answer 39

Open-ended question

Open-ended questions ask for narrative information and give the patient free rein. They state the topic to be discussed but only in general terms, which is what the statement in this question does. The nurse should use open-ended questions to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. Reflection and facilitation refer to the nurse’s (interviewer’s) verbal response of their reactions to the facts or feeling the patient has communicated. Direct questions elicit a one or two word answer such as yes or no. The statement in this question is eliciting more than a yes or no response, so it is not a direct question. Instead the statement in the question is an open-end question allowing the patient free rein on what to say.

Question 40

The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
Respirations are measured; then pulse and temperature.
Vital signs should be measured more frequently than in an adult.
Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant’s vital signs.

Answer 40

Respirations are measured; then pulse and temperature.

With an infant, the order of vital sign measurements is reversed to respiration, pulse, and temperature. Taking the temperature first, especially if it is rectal, may cause the infant to cry, which will increase the respiratory and pulse rate, thus masking the normal resting values. The vital signs are measured with the same purpose and frequency as would be measured in an adult.

Question 41

The nurse is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
  Turgor
  Texture
  Density
  Consistency

Answer 41

Density

Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor, texture, and consistency are assessed with palpation.

Question 42

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
Increase in body weight from his younger years
Additional deposits of fat in the cheeks and forearms
Presence of kyphosis and flexion in bilateral knees and hips
Change in overall body proportion, including a longer trunk and shorter extremities

Answer 42

Presence of kyphosis and flexion in bilateral knees and hips

Changes that occur in the aging person include postural changes of kyphosis and slight flexion in the knees and hips. Other changes that occur with aging include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur. Changes that occur in the aging person include decreased body weight (especially in men), not increased body weight; a decrease in subcutaneous fat from the face and periphery, not an increase; and additional fat deposited on the abdomen and hips. Change in overall body proportion does occur but includes a shorter trunk with relatively longer extremities because long bones do not shorten with age rather than a longer trunk and shorter extremities.

Question 43

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first?
  Affect and mood
  Memory and affect
  Cognitive abilities
  Level of consciousness

Answer 43

Level of consciousness

The sequence of steps for a mental status examination forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be assessed accurately to ensure validity for the steps that follow (i.e., if consciousness is clouded, the person cannot be expected to have full attention and to answer accurately or cooperate with new learning).

Question 44

Which technique is correct when the nurse is assessing the radial pulse of a patient?
Palpate for 1 minute, if the rhythm is irregular.
Palpate for 15 seconds and multiply by 4, if the rhythm is regular.
Palpate for 2 full minutes to detect any variation in amplitude.
Palpate for 10 seconds and multiply by 6, if the rhythm is regular and the patient has no history of cardiac abnormalities.

Answer 44

Palpate for 1 minute, if the rhythm is irregular.

Research suggests that the 30-second interval multiplied by 2 is a more accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular, then the 15-seconds interval multiplied by 4 as any one beat error in counting results in an error of 4 beats/minute. If the rhythm is irregular, then the pulse is counted for 1 full minute.

Question 45

Which adjustment in the physical environment should the nurse make to promote the success of an interview?
Arrange seating across a desk or table.
Reduce noise by turning off televisions and radios.
Reduce the distance between the interviewer and the patient to 2 feet or less.
Provide dim lighting to make the room cozy and help the patient relax.

Answer 45

Reduce noise by turning off televisions and radios.

The nurse should secure a quiet environment, thus, should reduce noise by turning off the television, radio, and other unnecessary equipment, because multiple stimuli are confusing. The interviewer and patient should be approximately 4 to 5 feet apart; the room should be well-lit, enabling the interviewer and patient to see each other clearly. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. Having a table or desk in between the two people creates the idea of a barrier; equal-status seating, at eye level, is better. The interviewer and patient should be approximately 4 to 5 feet apart. Sitting closer than that to a patient, or encroaching on them, can cause anxiety. The room should be well-lit, enabling the interviewer and patient to see each other clearly.

Question 46

When examining an infant, the nurse should examine which area first?
  Ear
  Nose
  Throat
  Abdomen

Answer 46

Abdomen

The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last. Examination of the ear, nose, and throat are considered more invasive and the invasive steps of the examination should be performed last. The least-distressing steps, such as examination of the abdomen, should be performed first.