Questions Chapter 1

1.According to the holistic model, a narrow definition of holistic health includes:

A. an optimal functioning of mind, body, and spirit within the
environment.
B. the absence of disease.
C. the response of the whole person to actual or potential problems.
D. the internal and external environment.
2.What type of database is most appropriate when rapid collection of data is required and often
compiled concurrently with lifesaving measures?
A. Episodic

An episodic database is

for a limited or short-term problem; this database concerns mainly one

problem, one cue complex, or one body system
B. Follow-up
.A follow-up database is
used to follow up short-term or chronic health problems; the statuses of
identified problems are evaluated at regular and appropriate intervals.
C. Emergency
An emergency database
includes rapid collection of data often obtained concurrently with
lifesaving measures.
D. Complete

A complete database

includes a complete health history and a full physical examination; it

describes the current and past health state and forms a baseline against
which all future changes can be measured.
]3.A medical diagnosis is used to evaluate:
A. a persons state of health.

Nursing diagnoses are

clinical judgments about a persons response to an actual or potential

health state
B. the response of the whole person to actual or potential health problems.
Nursing diagnoses are
clinical judgments about a persons response to an actual or potential
health state
C. a persons culture.

The holistic model of

health care is used in nursing, and culture is an important factor to

consider in a nursing assessment.
D. the cause of disease.

Medical diagnoses are

used to evaluate the cause or etiology of disease.

4.An example of subjective data is:
A. decreased range of motion.

B. crepitation in the left knee joint.

C. left knee has been swollen and hot for the past 3 days.
D. arthritis.
5.What type of database is most appropriate for an individual who is admitted to a long-term care
facility?
A. Episodic

An episodic database is

for a limited or short-term problem; this database concerns mainly one

problem, one cue complex, or one body system
B. Follow-up
A follow-up database is
used to follow up short-term or chronic health problems; the statuses of
identified problems are evaluated at regular and appropriate intervals.
C. Emergency
.An emergency database
includes rapid collection of data often obtained concurrently with
lifesaving measures.
D. Complete

A complete database

includes a complete health history and a full physical examination; it

describes the current and past health state and forms a baseline against
which all future changes can be measured.
6.Which of the following is an example of objective data?

E.
F.
G.
H.

Alert and oriented

Dizziness
An earache
A sore throat

7.
An example of objective data is:
A. a complaint of left knee pain.
B. crepitation in the left knee joint.
C. left knee has been swollen and hot for the past 3 days.
D. a report of impaired mobility from left knee pain as evidenced by an
inability to walk, swelling, and pain on passive range of motion.
8.
A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
Medical diagnoses
determine the cause or etiology of disease.
B. a pattern of coping.

Coping patterns include

methods to relieve stress.

C. an individuals perception of health.

Health perception is how

the person describes and defines personal health.

D. a concise statement of actual or potential health concerns or level

of wellness.

Nursing diagnoses are

clinical judgments about a persons response to an actual or potential

health state.

9.A complete database is:

E. used to collect data rapidly and is often compiled concurrently with

lifesaving measures.
F. used for a limited or short-term problem usually consisting of one
problem, one cue complex, or one body system.
G. used to evaluate the cause or etiology of disease.
H. used to perform a thorough or comprehensive health history and
physical examination.
I. A complete database includes a complete health history and a full
physical examination; it describes the current and past health state and forms a baseline
against which all future changes can be measured. An emergency database is rapid
collection of data often obtained concurrently with lifesaving measures. An episodic
database is for a limited or short-term problem; this database concerns mainly one
problem, one cue complex, or one body system. Medical diagnoses are used to evaluate
the cause or etiology of disease.
10.
A patient admitted to the hospital with asthma has the following problems identified
based on an admission health history and physical assessment. Which problem is a first-level
priority?
A.
B.
C.
D.

Ineffective selfhealth management

Risk for infection
Impaired gas exchange
Readiness for enhanced spiritual well-being

Questions Chapter 2
1.Each culture has its own healers who usually:
A. speak at least two languages.
B. own and operate specialty community clinics.
C. cost less than traditional or biomedical providers.
D. recommend folk practices that are dangerous.
2.While evaluating the health history, the nurse determines that the patient subscribes to
the hot/cold theory of health. Which of the following would most likely describe this patients view
of wellness?
A.
B.
C.
D.

Good is hot.
Evil is hot.
The humors must be balanced.
The phlegm will be replaced with dryness.

he hot/cold theory of health is based on humoral theory;

the treatment of disease is based on the balance of the humors. Beverages,

foods, herbs, medicines, and diseases are classified as hot or cold according to
their perceived effects on the body, not their physical characteristics. Beverages,
foods, herbs, medicines, and diseases are classified as hot or cold according to
their perceived effects on the body, not their physical characteristics. The four
humors of the body include the blood, phlegm, black bile, and yellow bile; the
humors regulate basic bodily functions and are described in terms of
temperature, dryness, and moisture. The treatment of disease consists of adding
or subtracting cold, heat, dryness, or wetness to restore the balance of the
humors.
3.On the basis of median age:
A. the non-Hispanic white population tends to be younger.
B. the Hispanic population tends to be older.
C. the Asian population tends to be younger.
D. minorities tend to be older than non-Hispanic white populations.
E. The Asian population is younger with a median age of 36 years. The nonHispanic, single-race white population is older than the population as a whole; the
respective median age is 40.2 years. The Hispanic population is much younger, with a
median age of 27.7 years. Minorities tend to be younger than non-Hispanic white
populations.
4.Spirituality is defined as:
A. participating in religious services on a regular basis.
B. a personal effort to find meaning and purpose in life.
C. the process of being raised within a culture.
D. a social group that claims to possess variable traits.
E. Spirituality is a personal effort to find purpose and meaning in life.
Religion refers to an organized system of beliefs concerning the cause, nature, and
purpose of the universe. Socialization is the process of being raised within a culture and
acquiring the characteristics of that group. Ethnicity pertains to a social group within the
social system that claims to possess variable traits.

5.Which of the following statements regarding language barriers and health care is true?
A. There is a law that addresses language barriers and health care.
B. Limited English proficiency is associated with a higher quality of care.
C. English proficiency is associated with a lower quality of care.
D. Patients with language barriers have a decreased risk of nonadherence
to medication regimens.
6.What is the yin/yang theory of health?
A. Health exists when all aspects of the person are in perfect balance.
B. Health exists when physical, psychological, spiritual, and social
needs are met.
C. Health exists in the absence of illness.

D. Health exists when there is optimal functioning.

E. In the yin/yang theory, health is believed to exist when all aspects of the
person are in perfect balance. In the hot/cold theory, health consists of a positive state of
total well-being, including physical, psychological, spiritual, and social aspects of the
person. The biomedical model of Western tradition views health as the absence of
disease. In the biomedical or scientific theory, high-level wellness (or health) exists with
optimal functioning of the human body.
7.Which theory has been expanded in an attempt to study the degree to which a persons
lifestyle reflects his or her traditional heritage?
A. Behavior theory
B. Heritage consistency
C. Congruence mechanism
D. Socialization experience
E. Heritage consistency theory has been expanded in an attempt to study
the degree to which a persons lifestyle reflects his or her traditional heritage. Behavior
theory or behaviorism is a learning theory. Carl Rogers described the concepts of
congruence and incongruence as important ideas in his theory of personality and human
development. Socialization is the process of being raised within a culture and acquiring
the characteristics of that group.
8.Which of the following symptoms is greatly influenced by a persons cultural heritage?
A. Hearing loss
B. Pain
C. Breast lump
D. Food intolerance
9.When considering cultural competence, the nurse must develop knowledge of discrete
areas to understand the health care needs of others. These discrete areas include understanding
of: (Select all that apply.)
A. his or her own heritage.
B. cultural and ethnic values.
C. the heritage of the nursing profession.
D. the heritage of the patient.
E. the heritage of the health care system.

Questions Chapter 3

1.When preparing the physical setting for an interview, the interviewer should:
A. set the room temperature between 64 F and 66 F.
B. reduce noise by turning the volume on the television or radio
down.
C. conduct the interview at eye level and at a distance of 4 to 5
feet.
D. stand next to the patient to convey a professional demeanor.
E. Both the interviewer and the patient should be at eye level at a
distance of 4 to 5 feet. The room temperature should be set at a comfortable
level; a temperature between 64 F and 66 F is too cool. Turn off the television
or radio and any unnecessary equipment to reduce noise. The interviewer and
the patient should be comfortably seated; standing communicates haste and
assumes superiority.
2.Parents or caretakers accompany children to the health care setting. Starting at ___
years of age, the interviewer asks the child directly about his or her presenting symptoms.
A. 5
B. 7
C. 9
D. 11
E. School-age children (starting at age 7) have the verbal ability to
add important data to the history. The nurse should interview the parent and
child together, but when a presenting symptom or sign exists, the nurse should
ask the child about it first and then gather data from the parent.
3.Which of the following statements made by the interviewer would be an appropriate
response?
A. I know just how you feel.
B. If I were you, I would have the surgery.
C. Why did you wait so long to make an appointment?
D. Tell me what you mean by bad blood.
E. Tell me what you mean by bad blood is an appropriate
communication technique referred to as seeking further clarification. I know
just how you feel is an inappropriate communication technique referred to as
false reassurance. If I were you, I would have the surgery is an inappropriate
communication technique referred to as giving unwanted advice. Why did you
wait so long to make an appointment? is an inappropriate communication
technique referred to as using Why questions.
4.While discussing the treatment plan, the nurse infers that the patient is uncomfortable
asking the physician for a different treatment because of fear of the physicians reaction. In this
situation, the nurses verbal interpretation:
A. affects the nurse-physician relationship.
B. impedes further discussion.

C. helps the patient understand personal feelings in relation to

his or her verbal message.
D. helps the nurse understand his or her own feelings in relation to
the patients verbal message.
5.The use of euphemisms to avoid reality or to hide feelings is known as:
A. distancing language.
B. sympathetic language.
C. avoidance language.
D. ethnocentric language.
E. Euphemisms are used to avoid reality or to hide feelings. Using
direct language is the best way to deal with frightening topics instead of using
avoidance language. Distancing is the use of impersonal speech to put space
between a threat and the self. Empathy means viewing the world from the other
persons inner frame of reference. Empathy is therapeutic; sympathy is
nontherapeutic. Ethnocentrism is the belief that ones ethnic or cultural group is
more important or superior.
6.When addressing a toddler during the interview, the health care provider should:
A. ask the child, before the caretaker, about symptoms.
B. use nonverbal communication.
C. use short, simple, concrete sentences.
D. use detailed explanations.

7.Nonverbal communication is the primary form of communication for which group of

individuals?
A.
B.
C.
D.

Infants
Preschoolers
Adolescents
Older adults

8.Viewing the world from another persons inner frame of reference is called:
A. reflection.
B. empathy.
C. clarification.
D. Sympathy.
E. Empathy means viewing the world from the other persons inner
frame of reference. Reflection is repeating part of what the person has just said.
Clarification is used to summarize the persons words or to simplify the words to
make them clearer. Sympathy is a social affinity in which one person stands
with another person, closely understanding his or her feelings.
9.An example of an open-ended question or statement is:
A. Tell me about your pain.
B. On a scale of 1 to 10, how would you rate your pain?

C. I can see that you are quite uncomfortable.

D. You are upset about the level of pain, right?
E. Open-ended questions and statements ask for narrative
information; they state the topic to be discussed but only in general terms. Tell
me about your pain encourages the person to respond in paragraphs and to
give a spontaneous account in any order chosen. On a scale of 1 to 10, how
would you rate your pain?; I can see that you are quite uncomfortable; and
You are upset about the level of pain, right? are closed or direct questions.
Closed or direct questions and statements ask for specific information. This
type of question or statement will elicit a short, one- or two-word answer, a yes
or no response, or a forced choice.
10.The most appropriate introduction to use to start an interview with an older adult
patient is:
A. Mr. Jones, I want to ask you some questions about your
health so that we can plan your care.
B. David, I am here to ask you questions about your illness; we
want to determine what is wrong.
C. Mr. Jones, is it okay if I ask you several questions this morning
about your health?
D. Because so many people have already asked you questions, I
will just get the information from the chart.

Chapter 4 Questions
https://quizlet.com/55947129/hesi-prep-health-assessment-practice-questions-flash-cards/

1.Which of the following is included in documenting a history source?

A. Appearance, dress, and hygiene
B. Cognition and literacy level
C. Documented relationship of support systems
D. Reliability of informant
E. The source of history is a record of who furnishes the
information, how reliable the informant seems, and how willing he or she is to
communicate. In addition, there should be a note of any special circumstances,
such as the use of an interpreter. Appearance, dress, and hygiene are
observations included in the general survey. Cognition and literacy level are
part of the mental status assessment. Interpersonal relationships and resources
such as support systems are assessed during the functional assessment of the
complete health history.
2.A patient seeks care for "debilitating headaches that cause excessive absences at
work." On further exploration, the nurse asks, "What makes the headaches worse?" With this
question, the nurse is seeking information about:
A. the patient's perception of pain.
B. the nature or character of the headache.
C. aggravating factors.
D. relieving factors.
E. Aggravating factors are determined by asking the patient what
makes the pain worse. To determine the patient's perception of pain, the nurse
would determine the meaning of the symptom by asking how it affects daily
activities and what the patient thinks the pain means. The nature or character
calls for specific descriptive terms to describe the pain. Relieving factors are
determined by asking the patient what relieves the pain, what is the effect of
any treatment, what the patient has tried, and what seems to help.
3.The CAGE test is a screening questionnaire that helps to identify:
A. unhealthy lifestyle behaviors.
B. personal response to stress.
C. excessive or uncontrollable drinking.
D. Depression.
E. CAGE is a screening questionnaire to identify excessive or
uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener).
The health history assesses lifestyle, including factors such as exercise, diet,
risk reduction, and health promotion behaviors. Coping and stress management
are assessed during the functional assessment of the complete health history.
Depression is assessed during the review of systems and during the mental
status assessment (mood and affect). The Geriatric Depression Scale, Short
Form is an assessment instrument for use with older adults.
4.The "review of systems" in the health history is:
A. an evaluation of past and present health state of each body
system.
B. a documentation of the problem as perceived by the patient.
C. a record of objective findings.
D. a short statement of general health status.

E. The purpose of the review of systems is to evaluate the past and

present health state of each body system, to double-check in case any
significant data were omitted in the present illness section, and to evaluate
health promotion practices. The reason for seeking care is a statement in the
persons own words that describes the reason for the visit. This is typically
known as a "chief complaint" or the reason for the health care visit. Objective
data are the observations obtained by the health care professional during the
physical examination. A short statement related to the patient's general health
status is typically included in the complete physical assessment record.
5.When recording information for the review of systems, the interviewer must document:
A. physical findings, such as skin appearance, to support historic
data.
B. negative under the system heading.
C. the presence or absence of all symptoms under the system
heading.
D. objective data that support the history of present illness.
6.Assessment of self-esteem and self-concept is part of the functional assessment. Areas
covered under self-esteem and self-concept include:
A. education, financial status, and value-belief system.
B. exercise and activity, leisure activities, and level of
independence.
C. family role, interpersonal relations, social support, and time
spent alone.
D. stressors, coping mechanisms, and change in past year.
7.PQRSTU is a mnemonic that helps the clinician to remember to address characteristics
specific to:
A.
B.
C.
D.

severity of dementia.
substance use and abuse.
pain presentation.
the ability to perform activities of daily living (ADLs).
E. The eight critical characteristics of pain symptoms reported in the
history are: P = provocative or palliative; Q = quality or quantity; R = region or
radiation; S = severity scale; T = timing; and U = understand patients
perception. Tests used to assess for dementia include the Mini-Mental State
Examination, the Set Test, the Short Portable Mental Status Questionnaire, the
Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional
assessment includes questions on substance use and abuse. Functional

assessment measures a persons self-care ability including the ability to

perform ADLs.
8.The nurse questions the reliability of the history provided by the patient. One
method to verify information within the context of the interview is to:
A. review previous medical records.
B. rephrase the same questions later in the interview.
C. ask the patient if there is someone who could verify
information.

D. call a family member to confirm information.

9.When taking a health history from an adolescent, the interviewer should:
A. ask about violence and abuse before asking about alcohol
and drug use.
B. have at least one parent present during the interview.
C. interview the youth alone with a parent in the waiting
area.
D. ask every youth about the use of condoms.
10.What information is included in greater detail when taking a health history on an
infant?
A.
B.
C.
D.

Nutritional data
History of present illness
Family history
Environmental hazards

Chapter 05 - Mental Status Assessment

1. A full mental status examination should be completed if the patient:
A. has a change in behavior and the family is concerned.
B. develops dysphagia.
C. has a new diagnosis of type 2 diabetes mellitus.
D. complains of insomnia.
E. A full mental status examination is indicated if there is any
abnormality in affect or behavior and in the following situations: family
members concerned about a person's behavioral changes; brain lesions;
aphasia; or symptoms of psychiatric mental illness, especially with acute
onset. A full mental status examination is not indicated for dysphagia or
difficulty with swallowing. A full mental status examination is not indicated
for a medical problem such as type 2 diabetes mellitus. A full mental status
examination is not indicated for a symptom such as insomnia.
2.Aphasia is best described as:
A. a language disturbance in speaking, writing, or
understanding.
B. the impaired ability to carry out motor activities despite intact
motor function.
C. the impaired ability to recognize or identify objects despite
intact sensory function.
D. a disturbance in executive functioning (planning, organizing,
sequencing, abstracting).
E. Aphasia is a language disturbance. Apraxia is an impaired
ability to carry out motor activities despite intact motor function. Agnosia is
an impaired ability to identify objects correctly despite intact sensory

function. A disturbance in executive functioning is a cognitive disturbance.

Dementia is the development of multiple cognitive deficits with both memory
impairment and a cognitive disturbance.
3.A patient in whom a seizure disorder was recently diagnosed plans to continue a
career as a pilot. At this time in the interview, the nurse begins to question the patients:
A. thought process.
B. judgment.
C. perception.
D. Intellect.
E. To assess judgment in the interview, the nurse should notice
what the person says about job plans, social or family obligations, and
plans for the future. Job and future plans should be realistic and should take
into account the persons health situation. Thought processes should be
consistent, coherent, relevant, and logical. Perceptions should be
congruent; the person should be consistently aware of reality. Intellectual
functioning is measured by problem-solving and reasoning abilities.
4.A major characteristic of dementia is:
A. impaired short-term and long-term memory.
B. hallucinations.
C. sudden onset of symptoms.
D. cognitive deficits that are substance-induced.
E. Dementia is the presence of cognitive deficits; the deficits
include memory impairment (impaired ability to learn new information or to
recall previously learned information). Hallucinations are a form of delirium.
Delirium is a disturbance that develops over a short period of time. Delirium
may be substance-induced.
5.Mental status assessment documents:
A. emotional and cognitive functioning.
B. intelligence and educational level.
C. artistic or writing ability in the mentally ill person.
D. schizophrenia and other mental health disorders.
E. Mental status assessment is a systematic check of emotional
and cognitive functioning. Intelligence testing measures problem-solving
and reasoning abilities; results of intelligence testing should be assessed
considering educational and cultural background. Mental status assessment
evaluates appearance, behavior, cognition, and thought processes, not
artistic or writing ability. Abnormalities in mood and affect may indicate
schizophrenia and other mental health disorders.
6.Although a full mental status examination may not be required for every patient, the
health care provider must address the four main components during a health history and
physical examination. The four components are:
A. memory, attention, thought content, and perceptions.
B. language, orientation, attention, and abstract reasoning.
C. appearance, behavior, cognition, and thought processes.

D. mood, affect, consciousness, and orientation.

E. The four main components of a full mental status examination are
appearance, behavior, cognition, and thought processes. Select behaviors that are
assessed with a mental status examination include memory, attention, thought
content, and perceptions. Select behaviors that are assessed with a mental status
examination include language, orientation, attention, and abstract reasoning.Select
behaviors that are assessed with a mental status examination include mood, affect,
consciousness, and orientation.
7.An older adult:
A. experiences a 10-point decrease in intelligence.
B. has diminished recent and remote memory recall.
C. has a slower response time.
D. has difficulty with problem solving.
E. Response time is slower in an aging adult; it may take longer
for the brain to process information and react. Timed intelligence testing
may be lower for an aging adult; intelligence has not declined, but it may
take longer to respond to questions. Recent memory requires processing
and may decrease with aging. Remote memory is not affected by the aging
process. Aging does not usually have an impact on mental status (e.g.,
intelligence, reasoning abilities, and problem solving).
8.Which of the following statements about mental status testing of children is
correct?
A. The results of the Denver II screening test are valid for white,
middle-class children only.
B. The behavioral checklist is useful to assess children who are
3 to 5 years old.
C. Abnormal findings are usually related to not achieving
an expected developmental milestone.
D. Input from parents and caretakers is discouraged when
assessing psychosocial development.
9.Which of the following best illustrates an abnormality of thought process?
A. Lability
B. Blocking
C. Compulsion
D. Aphasia
E. Thought process is defined as the way a person thinks or as
the logical train of thought. Blocking is a sudden interruption in train of
thought. Lability is an abnormality of mood and affect; the person has a
rapid shift of emotions. A compulsion is an abnormality of thought content;
the person displays unwanted repetitive, purposeful acts. Aphasia is a
speech abnormality; the person is unable to comprehend language,
produce language, or both.
10.The mental status examination:

A. should be completed at the end of the physical examination.

B. will not be affected if the patient has a language impairment.
C. is usually not assessed in children younger than 2 years of
age.
D. assesses mental health strengths and coping skills and
screens for any dysfunction.
E. The purpose of the mental status examination is to assess
mental health strengths and coping skills and to screen for any dysfunction.
The mental status assessment usually can be completed during the context
of the entire health history interview. If basic functions (e.g., language) are
abnormal, other assessments (of new learning or abstract reasoning) may
be erroneous. A mental status examination can be performed on all
patients.

Review Questions - NCLEX - Chapter 06

1.The nurse would expect an older adult to have higher blood alcohol levels because
older adults have:
A. more lean muscle mass.
B. an increased consumption of alcohol.
C. decreased liver metabolism and kidney functioning.

D. increased gastrointestinal motility.

E. Older adults have numerous characteristics that can increase
the risk of alcohol use. Liver metabolism and kidney functioning are
decreased, which increases the bioavailability of alcohol in the blood for
longer time periods. Aging adults lose muscle mass; less tissue for the
alcohol to be distributed to means an increased alcohol concentration in the
blood. The prevalence of current alcohol use decreases with increasing
age. Older adults have decreased gastrointestinal motility.
2.For a patient to meet the criteria for a diagnosis of alcohol abuse, the patient must
report that alcohol has repeatedly caused or contributed to:
A. amnesia episodes while drinking.
B. relationship trouble with family or friends.
C. needing more than three drinks to feel the effects.
D. one or more family members complaining about alcohol use.
E. To meet the criteria for a diagnosis of alcohol abuse, the
patient must admit that drinking alcohol repeatedly causes or contributes to
one or more of the following occurring in the past 12 months: (1) risk of
bodily harm (drinking and driving, operating machinery, swimming); (2)
relationship trouble (family or friends); (3) role failure (interference with
home, work, or school obligations); or (4) run-ins with the law (arrests or
other legal problems). Amnesia indicates at-risk drinking. Taking three or
more drinks to feel high is termed tolerance. Family members complaining
about alcohol use is a sign of at-risk drinking.
3.If the patient has a drinking problem, which statement by the nurse is most
appropriate?
A. Your alcohol consumption is not that bad. You only need to
cut down on the amount by drinking only on the weekend.
B. I want you to record how much you drink over the next 2 to 3
months. This will help you to determine if you have a drinking problem.
C. If you continue to drink, you might develop serious health
problems. It is up to you to find help and the way to quit.
D. I believe that you have an alcohol problem and strongly
recommend that you quit drinking. I am willing to help.
4.A patient denies having a drinking problem. Which of the following laboratory tests
is commonly used as a biochemical marker that indicates chronic alcohol use?
A. Elevated gamma-glutamyl transferase (GGT)
B. Elevated serum aspartate aminotransferase (AST)
C. Elevated mean corpuscular volume (MCV)
D. Elevated blood alcohol content (BAC)
E. A serum protein GGT is the most commonly used biochemical
marker of alcohol drinking, especially of chronic alcohol use.

5.A patient with chronic alcohol use is most at risk for developing which of the following
cardiovascular diseases?

F. Bradycardia
G.
Deep vein thrombosis
H. Hypertension
I. Acute myocardial infarction
J. Chronic alcohol use is associated with increased risk of
alcoholic cardiomyopathy, hypertension, and atrial fibrillation. Chronic
alcohol use is associated with fast heart rates (tachycardia). Chronic
alcohol use does not increase the risk of deep vein thrombosis. Chronic
alcohol use is not associated with a higher incidence of acute myocardial
infarctions.
6.One of the most frequently abused prescription opioid pain medications is:
A. oxycodone.
B. meperidine.
C. morphine.
D. Propoxyphene.
E. The three most frequently abused prescription opioid pain
relievers are products using oxycodone, hydrocodone, and methadone.
Meperidine is not a frequently abused prescription pain medication.
Morphine is not a frequently abused prescription pain medication.
Propoxyphene is not a frequently abused prescription pain medication
7.A female patient asks the nurse about the safe use of alcohol before and during
pregnancy. The best response by the nurse is to instruct the patient to:
A. talk about alcohol use with the physician.
B. avoid alcohol before conception and during pregnancy.
C. reduce alcohol intake before pregnancy and to avoid alcohol
after a positive pregnancy test.
D. limit alcoholic beverages to two or fewer drinks per week
during pregnancy.
8. Patients should be instructed to consume alcohol in moderation. To consume at a
moderate drinking pattern, a female patient should be instructed to consume no more than:
A. two drinks per day.
B. one drink per day.
C. three drinks per week.
D. six drinks per week.
E. An adult should be instructed that alcohol intake should be moderate.
Recommendations for moderate drinking patterns for men is two or fewer drinks per
day; for women, the recommendation is one or fewer drinks per day.
9. Which alcohol screening test is specifically designed for use in older adults?
A. CAGE (Cutdown, Annoyed, Guilty, Eye opener)
B. TWEAK (Tolerance, Worry, Eye-opener, Amnesia, and Kut
down)

C. AUDIT (Alcohol Use Disorders Identification Test)

D. SMAST-G (Short Michigan Alcohol Screening Test
Geriatric Version)
E. The SMAST-G questionnaire is for older adults who report social or
regular drinking of any amount of alcohol. Older adults have specific emotional
responses and physical reactions to alcohol, and the 10 questions with yes/no
responses address these factors. The CAGE questionnaire works well in primary
care settings because it takes less than 1 minute to complete. The TWEAK questions
are a combination of items of two other questionnaires that help identify at-risk
drinking in women, especially pregnant women. The AUDIT questionnaire detects
less severe alcohol problems (hazardous and harmful drinking) and alcohol abuse
and dependence disorders. It is useful in primary care settings, with adolescents and
with older adults. The AUDIT covers three domains: alcohol consumption, drinking
behavior or dependence, and adverse consequences from alcohol.
10. If a patient admits not being able to quit drinking, having to have more drinks to
get the same effect, and having withdrawal symptoms, the patient meets criteria for:
A. at-risk drinking.
B. alcohol dependence.
C. hazardous drinking.
D. harmful drinking.
E. The criteria for a diagnosis of alcohol dependence are met if a
patient admits to three or more of the following: not being able to stick to
drinking limits (repeatedly going over them); not being able to cut down or
stop (repeated failed attempts); showing tolerance (needing to drink a lot
more to get the same effect); showing signs of withdrawal (tremors,
sweating, nausea, or insomnia when trying to quit or cut down); continuing
to drink despite problems (recurrent physical or psychological problems);
spending a lot of time drinking (or anticipating or recovering from drinking);
and spending less time on other matters (activities that have been important
or pleasurable). For men, consuming 14 or more drinks per week or 4 or
more drinks per occasion is at-risk drinking; for women, consuming 7 or
more drinks per week or 3 or more drinks per occasion is at-risk drinking. A
hazardous drinking pattern puts a person at high risk for future damage to
physical or mental health. Harmful drinking is defined as alcohol use that
already results in problems.

Chapter 07 - Domestic and Family Violence Assessments

1.Dehydration and malnutrition can be manifestations of ________________ in the
elderly.
A. intimate partner violence
B. physical abuse
C. neglect
D. psychological abuse
E. Neglect in an elderly person can manifest with symptoms of
dehydration and malnutrition. Neglect (physical) is defined as failure to
provide basic goods and services such as food, shelter, health care, and
medications. Intimate partner violence is identified by two types: physical or
sexual violence (physical force) and psychological/emotional abuse or
coercive tactics when there has been prior physical or sexual violence.
Physical abuse is physical injury caused by intentional or unintentional
harmful acts. Psychological abuse is defined as behaviors that result in
mental anguish.
2.Increased bruising and bleeding in elderly adults may be related to which of the
following?
A. Thinning of the skin
B. A reduction in the integrity of blood vessels
C. Ingestion of nonsteroidal anti-inflammatory drugs
D. Decreased fluid intake
E. Certain medications such as nonsteroidal anti-inflammatory
drugs increase the risk for bruising or bleeding complications. Thinning of
the skin in elderly adults increases the risk of skin breakdown and skin
diseases. Blood vessels grow more rigid with age. Dehydration and
decreased fluid intake may occur in older adults because of a decrease in
thirst sensation, inability to obtain fluids related to altered mobility, or
neglect.

3.American women are most often killed by:

A. a known sex offender.
B. a man convicted of a serious crime.
C. an intimate male partner.
D. a man with a substance use problem.
4.An extremely important part of the history and examination in situations of intimate
partner violence or elder abuse is the:
A. mental status examination.
B. family genogram.
C. history of the present illness.
D. skin assessment.
E. An extremely important part of the history and examination in
cases of intimate partner violence or elder abuse is a mental status
examination, both for potential head trauma and neurologic symptoms and
for mental health problems. A family genogram is not as important as the
mental status examination, skin assessment, and history. It is also important
to assess and document prior abuse, including intimate partner violence,
physical and sexual abuse, and rapes of all kinds. The skin assessment is
also an important part of the history and examination.
5.The health care system may help abused women by:
A. providing shelter from the abusive individual.
B. identifying abuse in the early stages.
C. providing financial and supportive services.
D. estimating the ages of bruises.
6.Abused women have been found to have significantly more health problems,
including:
A. cardiovascular disease.
B. cancer.
C. chronic pain.
D. chronic anemia.
7.Women are more likely to be physically or sexually assaulted by a:
A. family member.
B. stranger.
C. current or former intimate partner.
D. friend.
8.A woman seeks medical attention for a cut made by a knife during a physical
assault. The health care provider would document the cut as an:
A. ecchymosis.
B. incision.
C. avulsion.
D. Abrasion.
E. An incision is a cut or wound made by a sharp instrument. An
ecchymosis is a hemorrhagic spot or blotch in the skin or mucous
membrane that forms a nonelevated, rounded or regular, blue or purplish
patch. An avulsion is the tearing away of a structure or part. An abrasion is
a wound caused by rubbing the skin or mucous membrane.
9.Risk factors associated with child maltreatment include:

A. young parents (18 to 20 years old).

B. a family with more than four children.
C. a parent with chronic pain.
D. a disabled child.
E. Risk factors for child maltreatment include disabilities or mental
retardation in children that increase caregiver burden; social isolation of families;
parental lack of understanding of childs needs and child development; parental
history of domestic abuse, poverty, family disorganization, dissolution, and violence;
lack of family cohesion, substance abuse in family; young, single nonbiologic
parents; poor parent-child relationships; parental thoughts and emotions supporting
maltreatment behaviors; parental stress and distress (depression or mental health
conditions); and community violence. A young, single nonbiologic parent is a risk
factor associated with child maltreatment. Children in families with more than four
children are not more at risk for child maltreatment. Parental chronic pain is not a risk
factor associated with child maltreatment.
10.The nurse caring for an older adult suspects elder abuse. Which action is
appropriate?
A. Collect proof of abuse before notifying the authorities.
B. Confront the caretakers about the suspicion of abuse.
C. Notify the authorities of the suspected elder abuse.
D. Report the abuse if the older adult gives permission.
E. The nurse is a mandatory reporter of elder abuse and should notify
the authorities of suspected elder abuse. The nurse does not need proof of abuse
before calling the authorities. The nurse should not confront the caretakers if elder
abuse is suspected. The nurse does not need permission from the elder before
calling the authorities.

Chapter 08 - Assessment Techniques and Safety in the

Clinical Setting
1.To examine a toddler, the nurse should:
A. allow the child to sit on the parents lap.

B. remove the childs clothing at the beginning of the

examination.
C. ask the child to decide whether parents or siblings should be
present.
D. perform the assessment from head to toes.
2.Deep palpation is used to:
A. identify abdominal contents.
B. evaluate surface characteristics.
C. elicit deep tendon reflexes.
D. determine the density of a structure.
E. Deep palpation is used to identify abdominal contents. Light
palpation is used to evaluate surface characteristics. Percussion with a
reflex hammer is used to elicit deep tendon reflexes. Percussion is used to
determine the density (air, fluid, or solid) of a structure by a characteristic
note.
3.Amplitude is:
A. the intensity (soft or loud) of sound.
B. the length of time the note lingers.
C. the number of vibrations per second.
D. the subjective difference in a sounds distinctive overtones.
E. Amplitude is the intensity of sound. Duration is the length of
time the note lingers. Pitch is the number of vibrations per second (high or
low). Quality is the subjective difference owing to a sounds distinctive
overtones.
4.The dorsa of the hands are used to determine:
A. vibration.
B. temperature.
C. position of an organ.
D. fine tactile discrimination.
E. The dorsa (back) of hands and fingers are best for
determining temperature because the skin is thinner than on the palms. The
base of the fingers or ulnar surface of the hand is best for vibration. A
grasping action of the fingers and thumb is the best way to detect the
position, shape, and consistency of an organ or mass.The fingertips are
best for fine tactile discrimination.
5.Fine tactile discrimination is best achieved with the:
A. opposition of the fingers and thumb.
B. fingertips.
C. back of the hands and fingers.
D. base of the fingers.
E. The grasping action of the fingers and thumb is used to detect
the position, shape, and consistency of an organ or mass. The fingertips
are best for fine tactile discrimination such as skin texture, swelling,
pulsation, and presence of lumps. The dorsa (back) of hands and fingers
are best for determining temperature because the skin is thinner than on

the palms. The base of the fingers or ulnar surface of the hand is best for
detecting vibration.
6.A funduscopic examination is an examination of the:
A. inner ear.
B. pharynx.
C. internal structures of the eye.
D. nasal turbinates.
E. An ophthalmoscope is used for a funduscopic examination,
which is an examination of the internal structures of the eye. An otoscope is
used to visualize the ear canal and tympanic membrane. A flashlight or
penlight and tongue depressor are used to examine the pharynx. An
otoscope may also be used with a short, broad speculum to view the nasal
turbinates and nares.
7.Which of the following is considered when preparing to examine an older adult?
A. Base the pace of the examination on the patients needs
and abilities.
B. Avoid physical touch to avoid making the older adult
uncomfortable.
C. Be aware that loss will result in poor coping mechanisms.
D. Confusion is a normal, expected finding in an older adult.
8.When performing percussion, the examiner:
A. strikes the flank area with the palm of the hand.
B. strikes the stationary finger at the distal interphalangeal
joint.
C. strikes the stationary finger at the proximal interphalangeal
joint.
D. taps fingertips over bony processes.
E. To perform percussion, the examiner strikes the stationary finger at
the distal interphalangeal joint (just behind the nail bed).
9.At the end of the examination, the examiner should:
A. complete documentation before leaving the examination
room.
B. have findings confirmed by another provider.
C. compare objective and subjective data for discrepancies.
D. review the findings with the patient.
10.The examiner should use handwashing instead of an alcohol-based hand rub:
A. if the patient has an infection with Mycobacterium
tuberculosis.
B. if the patient has an infection with Clostridium difficile.
C. if the patient has an infection with hepatitis B virus.
D. if the patient is HIV positive.
E. The examiner should use the mechanical action of soap-and-water
handwashing when hands are visibly soiled and when patients are infected with
spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based
hand rub would be effective against M. tuberculosis. An alcohol-based hand rub

would be effective against hepatitis B virus. An alcohol-based hand rub would be

effective against HIV.