1.
Which step ensures that the assessment data are correct before proceeding with the
nursing process?
A. Clustering data
B. Validation
C. Implementation
D. Evaluation
Option 1
2. What is the purpose of taking a past health history?
A. To identify chronic health problems
B. To list health factors from the past that may affect current health problems
C. To identify additional health risks caused by preexisting conditions
D. All of the above
3. Knowing the patient's current state of health and reason for seeking care will help the
nurse:
A) Prioritize the patient's teaching needs.
B) Identify developmental needs.
C) Choose teaching methodologies.
D) Promote a healthy lifestyle.
4. The “P” in the mnemonic “PQRST” stands for:
A) Pain.
B) Purpose.
C) Precipitating.
D) Pinpoint.
5. Which of the following provides the most complete database for a nursing diagnosis?
A) The objective data collected
B) The subjective data collected
C) The subjective and objective data collected
D) The health history
6. The best method for documentation of the physical exam is to record data:
A) In order of your assessment.
B) By patient's main complaint.
C) By system.
D) With all normals and abnormals clustered.
7. The sections of the examination that are subjective in nature are the:
A) Vital signs, weight, and height.
B) Auscultation of the heart and lungs.
C) The family history and the current health status.
D) The testing of pupil size, reaction to light, and accommodation.
8. Asking a patient about her or his occupation is important to assist in identifying:
A) Insurance coverage.
B) Possible health risks.
C) Genetic mutations.
D) Developmental tasks.
9. He has sweaty palms, pallor, and irregular heart rate. Which finding is considered a
symptom?
A) Sweaty palms
B) Palpitations
C) Pallor
D) Irregular heart rate
10. The nursing assistant tells you, one patient is dyspneic with a pulse oximetry of 86
percent on room air, a postoperative patient is complaining of pain, a patient with
pneumonia has a temperature of 101, and another patient has an elevated blood
pressure (BP) of 170/100. Who would you assess first?
A) Dyspneic patient with pulse ox of 86 percent
B) Postop patient in pain
C) Patient with 101 temperature
D) Patient with 170/100 BP
11. A 25-year-old female patient complains of acute pain in her abdomen. The nurse
touches her arm and she recoils. The nurse should recognize that touch:
A) Increases pain sensation.
B) Is offensive to most individuals.
C) Is very personal and should be avoided.
D) Is interpreted differently by each culture.
12. When is it appropriate to utilize the focused physical assessment?
A) During the initial assessment for a yearly exam
B) On admission to the hospital for surgery
C) On admission of a patient in acute respiratory distress
D) All of the above
13. A patient's health practices and beliefs are part of the:
A) Psychosocial profile.
B) Current health problem.
C) Past health problem.
D) Developmental considerations.
14. After teaching healthcare behaviors to a patient, the nurse should:
A) Reteach the material two more times.
B) Follow up with another method of teaching.
C) Evaluate learning.
D) Develop another teaching plan.
15. Which of the following patient data would indicate a more thorough assessment is
needed in a specific area?
A) Age 32
B) African American ethnicity
C) Smokes 1 pack of cigarettes a day
D) Jogs 3 miles 5 days a week
16. When assessing a patient who has mobility problems or is bedridden:
A) The exam must be performed in the same way as with any other patient.
B) The exam must be performed in a clinic setting rather than a home or hospital setting.
C) It may be necessary to make adjustments in the order of the exam and get extra assistance.
D) The nurse must not perform exams on such patients because of their problems.
17. Communication techniques used during the exam should include all of the following
except:
A) Using a calm, caring, and professional manner.
B) Teaching information, as appropriate, in response to the patient's health needs.
C) Being humorous about assessment findings.
D) Keeping the patient informed about assessment findings.
18. The nurse also attempts to elicit rebound tenderness. Which of the following
indicates positive rebound tenderness?
A) Pain during light palpation over the affected area
B) Pain during deep palpation over the affected area
C) Pain upon gradual withdrawal of fingers after light palpation
D) Pain upon sudden withdrawal of fingers after deep palpation
Option 5
19. The nurse assesses the ROM of the spine. Besides flexion, hyperextension, and
lateral bending, spinal ROM includes which other movement? *
A) Rotation
B) Circumduction
C) Inversion
D) Protraction
20. Which of the following questions may be the most helpful in identifying the cause of
a headache? *
A) What were you doing before the headache began?
B) Do any visual changes accompany the headache?
C) Does anything make the headache better?
D) What does it feel like?
