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Health Assessment > Prelim Exam > Flashcards

Prelim Exam Flashcards

1
Q 
This step begins after the care plan has been
made. This is the step where the nurse
performs the interventions as a means of
achieving goals.
a. Diagnosis
b. Assessment
c. Implementation
d. Planning
A

c. Implementation

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2
Q 
For efficient and effective provision of
nursing care, the GOSH approach I
recommended. What does the letter “O”
mean?
a. Outstanding
b. Observation
c. Organized
d. Outcome-based
A

c. Organized

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3
Q 
Performed to identify a life-threatening
problem (choking, stab wound, heart attack)
a. Emergency assessment
b. Focus assessment
c. Head-to-toe assessment
d. Initial assessment
A

a. Emergency assessment

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4
Q

Poverty and unemployment are two of the
_______.
a. societal factors that may lead to violence
b. factors that may lead to discrimination
c. causes of unintentional injuries
d. personality disorders that may lead to
violence

A

a. societal factors that may lead to violence

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5
Q 
Which of the following does not lead to
increased body temperature?
a. Illness or infection
b. Excitement
c. Starvation or fasting
d. Exercise
A

c. Starvation or fasting

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6
Q 
Vital signs are normally taken when the
person is
a. Only when sitting down
b. Only when lying down
c. Sitting or lying down
d. Sitting or standing
A

d. Sitting or lying down

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7
Q

Which assessment data should the nurse
include when obtaining a review of body
systems?
a. Information about the client’s sexual
performance and preference
b. Client complaints of chest pain, dyspnea, or
abdominal pain
c. Brief statement about what brought the
client to the health care provider
d. The client’s name, address, age, and phone
number

A

b. Client complaints of chest pain, dyspnea, or abdominal pain

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8
Q

The nurse is performing an assessment of a
client’s abdomen. Upon palpation, the nurse
feels an abnormal lump in the left upper
quadrant that is extremely painful for the
client. The nurse is likely palpating which of
the following?
a. Inflamed spleen
b. Enlarged liver
c. Inflamed appendix
d. Bilious gallbladder

A

a. Inflamed spleen

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9
Q 
You are assessing a client’s respiratory
patterns. You see that the respiratory rate is
greater than 20 breaths/minute. You should
record this abnormal finding as:
a. Eupnea
b. Apnea
c. Tachypnea
d. Bradypnea
A

c. Tachypnea

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10
Q 
Pulse rate is most commonly measured at
which site?
a. Apical
b. Temporal
c. Radial
d. Popliteal
A

c. Radial

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11
Q 
What factor does not influence respiratory
rate?
a. Gender
b. Smoking
c. Pain
d. Age
A

a. Gender

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12
Q 
Before taking vital signs on a patient, what
should you do first
a. Explain the procedure
b. Place the call bell within reach
c. Close the privacy curtain
d. Introduce yourself
A

d. Introduce yourself

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13
Q 
In this stage, you determine if the patient has
achieved the expected outcomes.
a. Assessment
b. Evaluation
c. Diagnosis
d. Implementation
A

b. Evaluation

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14
Q 
A patient with tachycardia MOST likely has
a/an:
a. Increased respiratory rate
b. Increased pulse rate
c. Elevated temperature
d. Elevated BP
A

b. Increased pulse rate

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15
Q

Physical assessment is being performed to
Raven Kyle by Nurse Mylene. During the
abdominal examination, Mylene should
perform the four physical examination
techniques in which sequence?
a. Palpation of tender areas first and then
inspection, percussion, and auscultation
b. Inspection and then palpation, percussion,
and auscultation
c. Percussion, followed by inspection,
auscultation, and palpation
d. Auscultation immediately after inspection
and then percussion and palpation

A

d. Auscultation immediately after inspection and then percussion and palpation

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16
Q 
One of the main predictors of domestic
violence is \_\_\_\_\_\_\_.
a. personal bankruptcy
b. marital dissatisfaction
c. a second marriage
d. tobacco use
A

b. marital dissatisfaction

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17
Q 
Angela, a 40-year-old mother of two,
withheld insulin from her diabetic mother
because she thought it cost too much. This is
an example of:
a. Battered parent syndrome.
b. Attempted homicide.
c. Elder abuse.
d. Parental negligence.
A

c. Elder abuse

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18
Q

Which of the following is an example of
subjective data?
a. The patient has a BP of 110/40.
b. The patient tells you her migraines have
gotten worse since beginning nursing school.
c. The patient presents with shaky hands.
d. The patient has a pulse of 79.

A

b. The patient tells you her migraines have gotten worse since beginning nursing school

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19
Q 
Newly hired nurse Maureen Mae is excited
to perform her very first physical assessment
with a 19-year-old client. Which assessment
examination requires Maureen Mae to wear
gloves?
a. Integumentary
b. Oral
c. Breast
d. Ophthalmic
A

b. Oral

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20
Q 
What is the most important part of
communication?
a. Giving ample time for your patient to
respond.
b. Being assertive.
c. Listening
d. Speaking clearly and directly.
A

c. Listening

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21
Q 
You are taking a health history on a patient
and notice their eyes seem a bit yellow and
their skin seems Jaundiced, what
word/phrase best describes this type of
objective observation?
a. An emergency.
b. A sign.
c. A symptom.
d. A complication of treatment.
A

b. A sign

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22
Q 
Priorities are established to help the nurse
anticipate and sequence nursing
interventions when a client has multiple
problems or alterations. Priorities are
determined by the client’s:
a. Physician
b. Future well-being
c. Urgency of problems
d. Non Emergent, non-life threatening needs
A

c. Urgency of problems

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23
Q

The planning step of the nursing process
includes which of the following activities?
a. Setting goals and selecting interventions
b. Evaluating goal achievement
c. Assessing and diagnosing
d. Performing nursing actions and
documenting them

A

a. Setting goals and selecting interventions

24
Q 
You should document that a client
complaining of an unpleasant itching
sensation has:
a. Pressure ulcers
b. Pruritus
c. Erythema
d. Striae
A

b. Pruritus

25
Q 
What should a nurse look for when
inspecting a patient’s skin for signs of
melanoma?
a. Pale patches on the skin
b. Flat areas of discoloration
c. Black or purple irregularly shaped nodules
d. Flaking of skin that won’t go away
A

c. Black or purple irregularly shaped nodules

26
Q 
Collaborative interventions are therapies
that require:
a. Client and Physician intervention.
b. Nurse and client interventions.
c. Physician and nurse interventions.
d. Multiple health care professionals.
A

d. Multiple health care professionals

27
Q 
Once a nurse assesses a client’s condition
and identifies appropriate nursing
diagnoses, a:
a. Physical assessment begins.
b. Plan is developed for nursing care.
c. List of priorities is determined.
d. Review of the assessment is conducted with
other team members.
A

b. Plan is developed for nursing care

28
Q

What is the normal pulse rate?

a. 60-100
b. 12-20
c. 50-80
d. 15-20

A

a. 60-100

29
Q 
In this step of the nursing process, you
prioritize the diagnosis in order of
importance and figure out what nursing
interventions need to take place to
accomplish these as well as goals to achieve
your care plan
a. Assessment
b. Implementation
c. Planning
d. Evaluation
A

c. Planning

30
Q

Mrs. Noel was admitted to the emergency
department of UC Medical Center with a
fractured arm. She explains to the nurse that
her injury resulted when she provoked her
drunken husband. Mr. Paelma, who then
pushed her. Which of the following best
describes the nurse’s understanding of the
wife’s explanation?
a. Mrs. Paelma’s explanation is an atypical
reaction of an abused woman.
b. Mrs. Paelma’s explanation is a typical
response of a victim accepting blame for the
abuser.
c. Mrs. Paelma’s explanation is appropriate
acceptance of her responsibility.
d. Mrs. Paelma’s explanation is evidence that
the woman may be an abuser as well as a
victim.

A

b. Mrs. Paelma’s explanation is a typical response of a victim accepting blame for the abuser.

31
Q

Alopecia is a term which means excessive
hair growth.
a. False
b. True

A

a. False

32
Q

Nurse Rhannel is working in the emergency
department of UC Medical Center. He is
conducting an interview with a victim of
spousal abuse. Which step should the
Rhannel take first?
a. Contact the appropriate legal services.
b. Establish a rapport with the victim and the
abuser.
c. Ensure privacy for interviewing the victim
away from the abuser.
d. Request the presence of a security guard.

A

c. Ensure privacy for interviewing the victim away from the abuser.

33
Q

Abuse is a family matter, it’s no one else’s
business.
a. False
b. True

A

a. False

34
Q 
In a blood pressure measurement of 132/86,
the number 86 is the:
a. Tachycardia
b. Diastolic
c. Bradycardia
d. Systolic
A

b. Diastolic

35
Q

When the nurse is conducting the physical
examination, which of the following findings
should be reported to the physician based on
the client’s symptoms?
a. Bowel sounds present in all four quadrants
b. Symmetrical abdomen
c. Tenderness to palpation of lower quadrants
with guarding
d. Warm skin

A

c. Tenderness to palpation of lower quadrants with guarding

36
Q

A pulse site at the neck is the

a. Popliteal
b. Temporal
c. Carotid
d. Femoral

A

c. Carotid

37
Q 
During the health assessment, the nurse
reviews the client's laboratory data. This is
an example of:
a. A primary source of information
b. A secondary source of information
c. Constant data
d. Subjective data
A

b. A secondary source of information

38
Q 
Any localized areas of skin or tissue
breakdown due to pressure on the skin
should be documented in the health
assessment as
a. Striae
b. Scars
c. Erythema
d. Pressure ulcers
A

d. Pressure ulcers

39
Q 
Eyes that itch and tear more than usual, and
a reddened sclera are symptoms of:
a. Conjunctivitis
b. Cataracts
c. Glaucoma
d. Jaundice
A

a. Conjunctivitis

40
Q

In applying the principles of pain treatment,
what is the first consideration?
a. Treatment is based on client goals.
b. The client must be believed about
perceptions of own pain.
c. A multidisciplinary approach is needed.
d. Drug side effects must be prevented and
managed.

A

b. The client must be believed about perceptions of own pain

41
Q

Deliberate, intentional acts that cause harm
or the threat of harm to a child are _______.
a. child abuse
b. child discipline
c. child abandonment
d. child neglect

A

a. child abuse

42
Q 
Which term would the nurse use to
document pain at one site that is perceived
in another site?
a. Referred pain
b. Intractable pain
c. Phantom pain
d. Chronic pain
A

a. Referred pain

43
Q

Clubbed fingers are a sign of:

a. Malnutrition
b. Bacterial infection
c. Oxygenation problem
d. Allergic reaction

A

c. Oxygenation problem

44
Q

The nurse is looking at the information
collected during the health interview in an
effort to cluster or group the data together.
The nurse is demonstrating which phase of
the nursing process?
a. Planning
b. Diagnosis
c. Assessment
d. Evaluation

A

b. Diagnosis

45
Q 
Difficult breathing with a high-pitched
whistling or sighing sound during expiration
is:
a. Wheezing
b. Crackles
c. Orthopnea
d. Apnea
A

a. Wheezing

46
Q

When doing a pain assessment for a patient
who has been admitted with Stage 4 breast
cancer, which question asked by the nurse
will give the most information about the
patient’s pain?
a. “How would you describe your pain?”
b. “How much medication do you take for the
pain?”
c. “How long have you had this pain?”
d. “How many times a day do you medicate for
pain?”

A

a. “How would you describe your pain?”

47
Q

Mang Gerard is a 73-year-old patient
diagnosed with pneumonia. Which data
would be of greatest concern to the nurse
when completing the nursing assessment of
the patient?
a. Hemoglobin concentration of 13 g/dl and
leukocyte count 5,300/mm3
b. Buccal cyanosis and capillary refill greater
than 3 seconds
c. Clear breath sounds and nonproductive
cough
d. Alert and oriented to date, time, and place

A

b. Buccal cyanosis and capillary refill greater than 3 seconds

48
Q

. Respiration is usually counted

a. After measuring the blood pressure
b. After taking the pulse
c. After taking the temperature
d. Before measuring the blood pressure

A

b. After taking the pulse

49
Q 
In a process of \_\_\_, nociceptors become
activated by the perception of potentially
damaging mechanical, thermal & chemical
stimuli
a. Modulation
b. Transmission
c. Perception
d. Transduction
A

d. Transduction

50
Q

After conducting the health interview, the
nurse begins to measure the client’s vital
signs. The nurse is collecting:
a. Secondary data
b. Objective data
c. Subjective data
d. Constant data

A

b. Objective data

51
Q 
It is synonymous with the PROBLEM SOLVING
APPROACH that directs the nurse and the
client to determine the need for nursing
care, to plan and implement the care and
evaluate result.
a. Nursing Plan
b. Nursing Process
c. Nursing Assessment
d. Nursing Diagnosis
A

b. Nursing Process

52
Q

This step of the nursing process includes the
systematic collection of all subjective and
objective data about the client in which the
nurse focuses holistically on the client physical, psychological, emotional,
sociocultural, and spiritual.
a. Planning
b. Implementation
c. Diagnosis
d. Assessment

A

d. Assessment

53
Q

Of the following, which person is MOST likely
to develop hypertension based on risk
factors
a. Obese 40-year-old African American male
smoker
b. Underweight 12-year-old Indian female
student
c. 30-year-old Asian male distance runner who
works as an air traffic controller
d. 45-year-old Caucasian mother of triplets
who is on a low carbohydrate diet

A

a. Obese 40-year old African American male smoker

54
Q

You are counting Mr. Gomez’s respiration.
Which statement is wrong?
a. Each rise and fall of the chest are counted as
one
b. Both sides of his chest should rise and fall
equally
c. Respirations are usually counted for 1
minute
d. You need to tell him what you are doing

A

d. You need to tell him what you are doing

55
Q

What is the respiratory rate of a patient who
is observed to have 16 inspirations and 16
expirations?
a. 16
b. 8
c. 64
d. 32

A

a. 16

56
Q 
A sphygmomanometer is an instrument used
to measure blood pressure in
a. mm BP
b. mm Ca
c. mm Na
d. mm Hg
A

d. mm Hg

57
Q

Louie Lee is about to take the Prelim
examination and is currently reviewing the
concept of pain. Which scientific rationale
would indicate that he understands the
topic?
a. Pain is an objective sign of a more serious
problem
b. Pain sensation is a subjective experience
c. Psychological factors rarely contribute to a
client’s pain perception
d. Intractable pain may be relieved by
treatment
e. Pain sensation is affected by a client’s
anticipation of pain

A

e. Pain sensation is affected by a client’s anticipation of pain

Health Assessment (13 decks)

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