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Nursing Health Assessment A Best Practice

Approach 1st edition by Jensen -Test Bank

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Nursing Health Assessment A Best Practice Approach 1st edition by Jensen -Test Bank

Chapter 06- General Survey and Vital Signs Assessment

As part of the general survey, the nurse should shake hands with the patient when first
1. meeting him or her as long as doing so is culturally appropriate. Why is this action so

A) The handshake portrays caring

B) The handshake shows how professional the nurse is

The handshake allows the nurse to get physically close to the patient in a nonthreatening

D) The handshake allows the nurse to assess how nervous the patient is
The nurse is caring for a newly admitted adult patient. When performing the general survey of
2. this patient, the nurse knows that accurate measurements provide critical information about

A) Safety B) State of health C) Growth pattern D) Past surgeries

3. What is the importance of assessing vital signs? (Mark all that apply.)

A) To identify pending problems

B) To plan how to improve a patient’s condition

C) To establish a baseline

D) To monitor risks for alterations in health

E) To evaluate the patient’s responses to treatment

The nurse’s aide reports to the nurse that a 98-year-old patient has abnormal vital signs. What
is important to remember in this type of situation?

A) At this patient’s age, abnormal vital signs are an indication of something serious

B) Normal readings get lower with advanced age

C) Normal readings get higher with advanced age

D) Normal readings vary according to age

5. How does the nurse use critical thinking when accurately assessing vital signs?

A) Evaluating assessment techniques C) Monitoring evaluations

B) Developing nursing diagnoses D) Planning assessment techniques

A patient arrives at the emergency department by ambulance after an accident while playing
6. softball. His left leg is swollen and deformed. He describes his pain as a 9 on a 10-point scale.
When the nurse assesses the patient’s blood pressure, what would he or she expect to find?

A) The blood pressure is lower than normal

B) There would be no need to assess the blood pressure

C) The blood pressure is elevated

D) The blood pressure is within normal limits

A 39-year-old man is at the gym exercising and develops a pain in his upper right quadrant. The
7. paramedics are called; their initial vital-sign readings indicate a pulse of 175 beats/min. This
pulse would be considered what? (Mark all that apply.)

A) Elevated due to pain

B) Elevated due to age

C) Elevated due to gender

D) Elevated due to activity

E) Elevated due to weight

A 68-year-old woman with COPD has come to the clinic for a routine follow-up visit. The nurse
8. escorts the patient to an examination room and measures vital signs. The nurse would expect
the patient’s vital signs to be what?

A) Higher than normal

B) Lower than normal


D) The nurse would not routinely take this patient’s vital signs

9. A nurse knows that normal blood pressure

A) Stays level throughout the day

B) Follows a diurnal rhythm

C) Rises with the early morning fall of blood glucose

D) Follows the same cycle as the sun

10. A student nurse studying hypertension would learn that the risk factors for it include what?

A) Family history, obesity, alcohol abstinence

B) Cigarette smoking, heavy alcohol consumption, hepatic disease

C) Prolonged stress, renal disease, heavy alcohol consumption

D) High cholesterol and triglyceride levels, family history, hepatic disease

A nurse is teaching a class on hypertension at the local Chamber of Commerce meeting. What
risk factor would the nurse be sure to address to the class?

A) Quitting cigarette smoking 5 years ago

B) Loss of 50 pounds within the last 12 months

C) High cholesterol and low triglyceride levels

D) Family history

A nurse is caring for a 36-year-old woman with a temperature of 38.9°C. The nurse administers
12. Tylenol, 2 tablets, as per orders. What is the most correct place in which to record the effect of
the medication administration on the patient’s temperature?

A) Nurse’s notes B) Vital sign flow sheet C) Progress notes D) MAR

While assessing respirations and heart rate in an 8-year-old patient, the nurse finds that the
13. patient’s heart rate increases during inspiration and decreases during expiration. What would
be the most correct way to document this finding?

A) The patient has an abnormal heart rate

B) The patient has a sinus arrhythmia

C) The patient’s heart rate speeds up and slows down in a cyclical pattern

D) The patient has a cardiopulmonary disorder

A nurse is admitting a new patient who is scheduled to have a five-vessel cardiac bypass in the
morning. Assessment reveals that the patient is very anxious. The nurse’s aide reports that the
patient’s vital signs are elevated. How would the nurse document these findings in the
patient’s care plan?

A) Anxiety as evidenced by patient’s verbalizations

B) Abnormal temperature as evidenced by vital sign assessment

C) Anxiety as evidenced by increased heart rate and pulse

D) Cardiac status stable as evidenced by electrocardiogram WNL

General survey of a 27-year-old woman reveals that the patient is wearing eccentric makeup
and clothes. For what would the nurse perform further assessments?

A) Inadequate finances B) Depression C) Poor hygiene D) Mania

Student nurses are doing clinical hours on the medical-surgical unit. What additional
assessment should the student nurses make when they take patient vital signs?

A) Oxygen saturation B) Blood pressure C) Heart rate D) Mobility

An ICU nurse is caring for a patient in shock. To obtain an accurate set of vital signs, the nurse
17. uses a Doppler to obtain pulse and blood pressure. What would be the best technique for the
use of the Doppler on this patient? (Mark all that apply.)

A) Hold the probe firmly against the skin at the expected pulse site

B) Hold the probe perpendicular to the skin at the expected pulse site

C) Use the gel that is on the cart

D) Mark the location of the loudest sound

E) Move the probe slowly over the area of the expected pulse site

The nurse is caring for four patients on the short-stay unit. Which patient would cause the
nurse greatest concern?

A) A 10-year-old patient with a BP of 103/62

B) A 7-year-old patient with a sinus dysrhythmia

C) A 77-year-old patient with a resting heart rate of 69 beats/min

D) An 82-year-old patient with a temperature of 37.2°C

The nurse is performing assessments on several male patients. The first one is 52 years old and
African American. The second one is 54 years old and Mexican American. The third one is 50
years old and Native American. The fourth one is 60 years old and Caucasian. Which patient
would the nurse expect to be tallest?

A) Caucasian C) Mexican American

B) African American D) Native American

Answer Key
1. A

2. B

3. C, D, E

4. D

5. B

6. C

7. A, D

8. A

9. B

10. C

11. D

12. A

13. B

14. C

15. D

16. A

17. B, D, E

18. D

19. A

Chapter 07- Pain Assessment

1. What is the most commonly accepted theory of pain?

A) Pain stimulus theory C) Pain transmission theory

B) Gate control theory D) Gatekeeper theory

2. On what does current research on pain focus?

A) Elements that can affect the intensity of pain

B) Stopping the cause of pain

C) Elements that can affect pain inhibition

D) Stopping the sensation of pain

3. The element of pain transmission that causes nociceptors to perceive a nerve impulse is what?

A) Transduction B) Transmission C) Perception D) Modulation

Both the peripheral and the central nervous systems are involved in the transmission of a pain
4. stimulus. When there is continued input from the peripheral nervous system, what can

A) Fibromyalgia

B) A peripherally mediated pain syndrome

C) Neuronal plasticity

D) A centrally mediated pain syndrome

The nursing instructor is discussing the different types of pain with the nursing class. What type
5. of pain would the instructor explain to the students that originates from a specific site, yet the
patient feels the pain at another site?

A) Chronic pain B) Cutaneous pain C) Referred pain D) Somatic pain

A nurse is caring for a patient who reports constant pain. The nurse knows that constant pain
6. can lead to the modification of the function of the nervous system, which can, in turn, lead to

A) Neuronal windup C) Neuronal plasticity

B) Peripheral sensitization D) Chronic pain

Pain is often untreated or undertreated; when this occurs, chronic pain may result. What can
be the outcome?

A) Chronic sensitization syndrome C) Complex regional pain syndrome

B) Peripheral sensitization syndrome D) Fibromyalgia pain syndrome

What is an excitatory process caused by pain stimuli that involves the spinal nerves and can
persist when there is no longer stimulation?

A) Central sensitization C) Peripheral sensitization

B) Neuronal windup D) Neuronal plasticity

A 52-year-old woman comes to the clinic reporting pain in her right lower quadrant. When
assessing the patient’s pain, what elements would the nurse include? (Mark all that apply.)

A) Aggressiveness

B) Intensity

C) Quality

D) Functional goal

E) Quantity
The nurse is assessing a 17-year-old boy with a history of drug addiction. What will be helpful
10. in determining interventions that will be most beneficial for providing adequate pain relief to
this patient?

A) Gathering information that the patient wants to share about his pain

B) Using in-depth questions to collect salient data about the patient’s pain

C) Collecting objective data that the patient chooses to share

D) Collecting subjective data that the nurse notes during assessment

A pediatric nurse is assessing a 4-week-old boy who has just been admitted to the pediatric
11. unit with a diagnosis of possible pyloric stenosis. When assessing this patient, what behavior
would indicate pain in this newborn to the nurse?

A) Closed lips B) Extended fingers C) Nasolabial fold D) Eye widening

A 5-year-old girl is admitted to the postanesthesia care unit after the repair of her fractured
12. femur. What activities would best indicate pain in this child according to the FLACC scale?
(Mark all that apply.)

A) Leg movement

B) Arched back

C) Sleep

D) Eye widening

E) Difficulty consoling

A nurse in the emergency department is caring for a patient who is nonverbal following a
13. traumatic injury. What would be the best way for the nurse to assess this patient’s level of

A) Ask the patient to draw a picture of the pain

B) Ask the paramedics what they think is the patient’s pain level

C) Ask the patient to describe the pain

D) Ask the family if they have noticed any changes in the patient’s behavior

When a patient with opioid tolerance has an altered physiologic response to pain stimuli, he or
she develops a form of pain sensitivity called what?

A) Opioid hyperalgesia C) Opioid hypoalgesia

B) Pain hyperactivity D) Pain hypoactivity

15. What are the steps for pain transmission in the gate control theory? (Mark all that apply.)

A) Unrelieved painful stimulus on a peripheral neuron causes the “gate” to open

B) The gate opens through repolarization of the nerve fiber

C) The brain stem recognizes the stimulus as pain

D) The pain stimulus passes down the afferent pathway

E) The pain stimulus crosses the dorsal horn of the spine to the limbic system

The Joint Commission mandates that nurses assess and reassess a patient’s pain level. A
16. nurse’s institution mandates pain reassessment at 30 minutes for any drug given intravenously.
This mandate is based on what?

Research that shows that it takes half as long for IV pain medication to work than oral

B) The time it takes a pain medication to decrease pain intensity

C) The time it takes a pain medication to block pain in a patient

D) The median half-life of an intravenous pain medication

What is the best description of the pain phenomena felt in rheumatoid arthritis and

A) Neuronal windup C) Peripheral sensitization

B) Neuronal plasticity D) Central sensitization

The nurse is assessing the pain of an 86-year-old man who is recovering from a right hip open
18. reduction procedure. What element would the nurse know it is important to review to best
understand the patient’s pain?

A) Sleep patterns C) Genetic history

B) Family history D) Elimination pattern

A 78-year-old patient is admitted to the unit with abdominal pain. The nurse doing the
admission assessment knows what about pain in older adults?

A) Older adults have fewer nerve fibers; therefore, they feel less pain

B) Older adults may be reluctant to report pain

C) Older adults are always in chronic pain

D) Older adults are stoic and expect to be in pain

Answer Key

1. B

2. C

3. A
4. D

5. C

6. B

7. C

8. A

9. A, B, C, D

10. B

11. C

12. A, B, D, E

13. D

14. A

15. A, E

16. B

17. A

18. A

19. B