NUR 216 Exam #1

Question 1

The nurse is concerned that the patient has orthostatic hypotension due to the patient complaining of:

Accepted Answer

Dizziness and feeling lightheaded with position changes.

Question 2

Which consideration should the nurse recognize as a priority when interviewing the patient?

Accepted Answer

Developmental level

Question 3

Which principles of behavior should the student remember when conducting a health history? Select all that apply.

Accepted Answer

Remain sensitive., Demonstrate professional behaviors., Be nonjudgmental.

Question 4

What does the abbreviation OPQRST represent?

Accepted Answer

Onset, provocation, quality, radiation, severity, timing

Question 5

A nurse is assessing a radial pulse. What characteristics of the pulse must be documented? Select all that apply.

Accepted Answer

Pulse rhythm, Pulse rate, Pulse amplitude

Question 6

A patient is complaining of SOB and mild chest pain. What should be the FIRST action when starting a focused assessment?

Accepted Answer

Wash hands in front of patient.

Question 7

A nurse understands that he must observe the following characteristics to assess breathing. Select all that apply.

Accepted Answer

Rhythm, Rate, Effort, Depth

Question 8

You are performing a physical assessment. Which of the following are considered part of the general survey? SATA

Accepted Answer

Body structure, Patient appears healthy, Patient hygiene, Patient appears stated age

Question 9

The nurse is going to conduct a health history on a patient being seen in the ED. Which type of history will be done?

Accepted Answer

Focused

Question 10

The nurse is discussing food prep, with an obese PT, to determine education necessary. The nurse will ask all EXCEPT:

Accepted Answer

“What is your favorite restaurant to eat at?”

Question 11

A patient is in a hypertensive crisis, which is a medical emergency because his blood pressure is 180/121.

Accepted Answer

True

Question 12

An 88-year-old patient had a warm bath 10 min ago & a cup of hot tea 5 min ago. Which temp method should the nurse use?

Accepted Answer

Tympanic

Question 13

The purpose of measuring body mass index (BMI) is to estimate the amount of body fat.

Accepted Answer

True

Question 14

A nurse is working w/ a 21-year-old female to educate about balancing calories for a weight loss plan, which includes:

Accepted Answer

Consuming fewer calories through food and beverage.

Question 15

During the summarization phase of the interview it is important to:

Accepted Answer

Clarify the patient’s report, needs, feelings, and concerns.

Question 16

Communication is both verbal and nonverbal. Which are nonverbal visual cues to be aware of? Select all that apply.

Accepted Answer

Gestures., Frowning., No eye contact., Slouching in the chair.

Question 17

Normal respirations in adults are ___ to ___ breaths per minute.

Accepted Answer

12 to 20

Question 18

The patient complains that he has not voided in 24 hours. What is the best technique to assess a distended bladder?

Accepted Answer

Light Palpation

Question 19

Communication is a reciprocal conversation. Identify barriers to communication. Select all that apply.

Accepted Answer

Offering false reassurance., Stereotyping., Leading the patient., Asking too many questions.

Question 20

The percussion sound of normal healthy lungs is called resonance.

Accepted Answer

True

Question 21

The nurse knows, in assessing the patient for depression, to ask which of the following questions?

Accepted Answer

“Over the past 2 weeks have you felt down, depressed, or hopeless?”

Question 22

Which pain scale would be most appropriate to use for a patient who is unable to communicate pain?

Accepted Answer

PAINAD Scale

Question 23

Which of the following is the correct sequence in which to perform a physical assessment?

Accepted Answer

General survey, temperature, pulse, respiratory rate, blood pressure

Question 24

What is the nurse assessing when performing light palpation? Select all that apply.

Accepted Answer

Masses, Skin textures, Tenderness

Question 25

The nurse is admitting a patient who reported achy pain in the lower back for 6 months. Which type of pain is this?

Accepted Answer

Chronic

Question 26

The nurse is going to conduct a health history in a head-to-toe sequence, this is also known as a comprehensive history.

Accepted Answer

True

Question 27

A patient states, she thinks she is running a fever and has stomach discomfort. You are her RN. What should you do?

Accepted Answer

Go to the patient’s room and assess for fever and epigastric discomfort.

Question 28

A nurse knows that a proper fitting BP cuff should cover ____ of the distance from the patient’s elbow to the shoulder.

Accepted Answer

2/3

Question 29

The radial pulse is the most reliable site to assess heart rate.

Accepted Answer

False

Question 30

Which of the following is true about how culture can influence the interview process?

Accepted Answer

A patient may have different definitions & perceptions of health & illness.

Question 31

A nurse is preparing a patient for a VS assessment. Which question should the nurse ask prior to taking the VS?

Accepted Answer

“Have you had any caffeine or smoked in the past 30 minutes?”

Question 32

The medical term for difficulty swallowing is dysphasia.

Accepted Answer

False

Question 33

Health assessment is a foundational and priority nursing skill. This essential skill requires RNs to:

Accepted Answer

Identify normal and abnormal findings

NUR 216 Exam #1

Questions 33

NUR 216 Exam #1

Questions 33