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Nursing Assessment and Patient Care Techniques, Exams of Nursing

Liverpool Hope UniversityNursing

Various nursing assessment techniques and patient care procedures, including taking blood pressure, assessing patient strengths, organizing patient data, performing physical assessments, and administering medications. It also includes information on deep vein thrombosis prevention, range-of-motion exercises, and gait patterns.

Typology: Exams

2023/2024

Available from 02/28/2024

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NURS 210 - Exam 1 Practice Questions
a clinic nurse has been caring for an outpatient with low muscle mass. after a year, the
nurse observes that the patient's muscle mass has increased significantly. when asked
about this, the patient replies, "I've been exercising a lot." which type of exercise has the
patient most likely been performing?
1. ROM
2. aerobic
3. anaerobic
4. deep breathing - ansANSWER:
3. anaerobic
a nurse asks a patient several questions to determine how he may have gotten a
pressure ulcer. which of the Gordon's model of 11 functional health patterns would the
nurse address in her assessment? select all that apply
1. sleep-rest
2. elimination
3. pain and weakness
4. food and fluid intake
5. past medical history or family history - ansANSWER:
1. sleep-rest
2. elimination
4. food and fluid intake
a nurse finds that a patient with hypertension has an auscultatory gap. which should the
nurse do when taking the patient's blood pressure measurement? select all that apply.
1. stop midway and begin to inflate again
2. continue to listen until the cuff is deflated
3. pump up the cuff until no sound is heard, then let the air out
4. make sure the bell of the stethoscope is placed firmly over the artery
5. inflate the cuff just enough to hear the systolic pressure - ansANSWERS:
2. continue to listen until the cuff is deflated
4. make sure the bell of the stethoscope is placed firmly over the artery
a nurse is assigned to a 78-year-old patient with symptoms of H1N1 flu. the patient is
short of breath with a respiratory rate of 30 breaths/min. he lost his wife just a month
ago. the nurse's knowledge about this patient would result in which assessment
approach at this time? select all that apply.
1. a focused approach
2. a structured comprehensive approach
3. using multiple visits to gather a complete database
4. focusing on the functional health pattern of role-relationship
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NURS 210 - Exam 1 Practice Questions

a clinic nurse has been caring for an outpatient with low muscle mass. after a year, the nurse observes that the patient's muscle mass has increased significantly. when asked about this, the patient replies, "I've been exercising a lot." which type of exercise has the patient most likely been performing?

  1. ROM
  2. aerobic
  3. anaerobic
  4. deep breathing - ansANSWER:
  5. anaerobic a nurse asks a patient several questions to determine how he may have gotten a pressure ulcer. which of the Gordon's model of 11 functional health patterns would the nurse address in her assessment? select all that apply
  6. sleep-rest
  7. elimination
  8. pain and weakness
  9. food and fluid intake
  10. past medical history or family history - ansANSWER:
  11. sleep-rest
  12. elimination
  13. food and fluid intake a nurse finds that a patient with hypertension has an auscultatory gap. which should the nurse do when taking the patient's blood pressure measurement? select all that apply.
  14. stop midway and begin to inflate again
  15. continue to listen until the cuff is deflated
  16. pump up the cuff until no sound is heard, then let the air out
  17. make sure the bell of the stethoscope is placed firmly over the artery
  18. inflate the cuff just enough to hear the systolic pressure - ansANSWERS:
  19. continue to listen until the cuff is deflated
  20. make sure the bell of the stethoscope is placed firmly over the artery a nurse is assigned to a 78-year-old patient with symptoms of H1N1 flu. the patient is short of breath with a respiratory rate of 30 breaths/min. he lost his wife just a month ago. the nurse's knowledge about this patient would result in which assessment approach at this time? select all that apply.
  21. a focused approach
  22. a structured comprehensive approach
  23. using multiple visits to gather a complete database
  24. focusing on the functional health pattern of role-relationship
  1. scheduling a single extensive, structured interview to gather a detailed assessment - ansANSWER:
  2. a focused approach
  3. using multiple visits to gather a complete database a nurse is caring for a patient with a viral infection and fever. which nursing interventions are appropriate when caring for this patient? select all that apply.
  4. provide fluids
  5. administer routine antibiotics
  6. instruct patient to limit physical activity
  7. set the room temperature to 30 C to 34 C
  8. reduce external covering of the patient's body without causing shivering - ansANSWERS:
  9. provide fluids
  10. instruct patient to limit physical activity
  11. reduce external covering of the patient's body without causing shivering a nurse is unable to obtain the blood pressure (BP) reading of a patient using a functional sphygmomanometer. which nursing actions are appropriate? select all that apply
  12. the nurse should use an electronic BP device
  13. the nurse should use a Doppler ultrasonic device
  14. the nurse should assess for signs of reduced cardiac output
  15. the nurse should measure the patient's pulse and respiratory rate
  16. the nurse should measure BP in another arm and compare findings - ansANSWERS:
  17. the nurse should use a Doppler ultrasonic device
  18. the nurse should assess for signs of reduced cardiac output
  19. the nurse should measure the patient's pulse and respiratory rate a nurse is using the Braden Scale. which characteristic about a patient is the nurse assessing?
  20. perception of pain
  21. fall risk
  22. risk for skin breakdown
  23. risk for venous thrombosis - ansANSWER:
  24. risk for skin breakdown a patient on week-long bed rest is now performing isometric exercises. which nursing diagnosis best addresses the safety risks for this patient?
  25. risk for depressed mood (ICNP)
  26. impaired skin integrity (ICNP)
  27. disturbed body image (ICNP)
  28. risk for activity intolerance (ICNP) - ansANSWERS:
  29. risk for activity intolerance (ICNP)

an elderly patient reports headache, chills, fatigue, increased frequency of urination, and urine leakage. upon assessment, the nurse finds that the patient's temperature is 101°F, and the patient has confusion. which condition is supported by the assessment findings?

  1. hepatitis
  2. dementia
  3. pneumonia
  4. UTI - ansANSWERS:
  5. UTI Gordon's model of functional health patterns helps nurses focus on which aspects during health assessment?
  6. all areas of concern in the patient
  7. physical aspects of the patient
  8. patient's head-to-toe assessment
  9. patient's strengths during assessment - ansANSWER:
  10. patient's strengths during assessment how would the nurse organize patient data using the head-to-toe model?
  11. organizes assessment data of each body system and focuses on physical aspects
  12. organizes only the physical assessment data from the upper to lower extremities
  13. organizes health assessment data according to the areas of function from head to toe
  14. organizes general health status first, vital signs next, and physical assessment at the end - ansANSWER:
  15. organizes general health status first, vital signs next, and physical assessment at the end in a tripod stance, at what distance are crutches placed to the side of each foot? crutches are positioned 6 inches in front of the patient at a width of _______ inches to the side of each foot. - anscrutches are positioned at a distance of 6 inches in front of the patient at a width of 6 inches to the side of each foot in which order, from the first technique to the last, would the nurse perform a physical assessment? auscultation, palpation, inspection, percussion - ansANSWER: inspection, palpation, percussion, auscultation kegel exercises are an example of which type of exercise?
  16. ROM
  17. isotonic
  18. isometric
  19. passive - ansANSWER:
  20. isometric place the elements of a comprehensive assessment in the correct order
  21. health history
  1. thorough interview
  2. review of systems
  3. extensive physical head-to-toe assessment
  4. laboratory and diagnostic tests ordered by the PCP - ansANSWER:
  5. review of systems
  6. extensive physical head-to-toe assessment
  7. laboratory and diagnostic tests ordered by the PCP the nurse asks a patient to walk up and down a short flight of stairs. which type of exercise is the nurse instructing the patient to do?
  8. aerobic exercise
  9. passive exercise
  10. isometric exercise
  11. anaerobic exercise - ansANSWER:
  12. aerobic exercise the nurse fits elastic stockings on a patient following major abdominal surgery. the nurse explains to the patient that the stockings help prevent which condition?
  13. varicose veins
  14. muscular atrophy
  15. joint contractures
  16. deep vein thrombosis - ansANSWER:
  17. deep vein thrombosis the nurse has administered a narcotic analgesic to a patient for pain relief immediately before ambulation. Before and during ambulation, the nurse should closely monitor the patient for which adverse effects of the medication? select all that apply.
  18. sedation
  19. respiratory depression
  20. withdrawl
  21. dizziness
  22. confusion - ansANSWERS:
  23. sedation
  24. dizziness
  25. confusion the nurse is teaching a four-point gait to a patient. if the patient has understood the gait instructions correctly, what will be the pattern of the patient's gait?
  26. the left crutch and right foot will advance at the same time
  27. the right crutch and left foot will advance at the same time
  28. the right crutch will advance first followed by the left foot
  29. the right leg will advance first followed by the right crutch - ansANSWER:
  30. the right crutch will advance first followed by the left foot the nurse is teaching the parents of toddlers about the use of seat belts and vehicle safety. which nursing goal is behind this teaching?
  1. asking the patient directly
  2. validating with findings from a physical examination
  3. contacting the patient's previous doctor which actions are appropriate for the nurse to implement when a patient experiences orthostatic hypotension while walking? select all that apply.
  4. call for assistance
  5. assist the patient to sit down
  6. assess the patient's blood pressure and pulse
  7. continue to ambulate the patient to build endurance
  8. if the patient begins to faint, slowly lower them to the floor - ansANSWER:
  9. call for assistance
  10. assist patient to sit down
  11. assess the patient's blood pressure and pulse
  12. if the patient begins to faint, slowly lower them to the floor which actions does the nurse take during the working phase of a patient interview? select all that apply
  13. focuses on the purpose of the interaction
  14. assesses both verbal and nonverbal cues
  15. assesses the patient's educational needs
  16. uses a variety of communication techniques
  17. summarizes key findings of the physical exam - ansANSWER:
  18. focuses on the purpose of the interaction
  19. assesses both verbal and nonverbal cues
  20. assesses the patient's educational needs
  21. uses a variety of communication techniques which actions should be taken by the nurse to maximize the benefits of range-of-motion (ROM) exercises for an immobile patient? select all that apply.
  22. carry out passive ROM movements slowly and smoothly
  23. encourage active ROM as independently as possible
  24. move joints slightly past the point of resistance
  25. facilitate ROM exercise sessions two times per day
  26. perform exercises in the same order during each session
  27. inform the patient that ROM exercises may be painful - ansANSWER:
  28. carry out passive ROM movements slowly and smoothly
  29. encourage active ROM as independently as possible
  30. facilitate ROM exercise sessions two times per day
  31. perform exercises in the same order during each session which assessment finding does the nurse expect to observe in a child with cerebral palsy?
  32. spasticity
  33. paraplegia
  34. quadriplegia
  1. osteoarthritis - ansANSWER:
  2. spasticity which body mechanics principles should the nurse adopt to prevent injury at work? select all that apply.
  3. bend at the knees
  4. pull rather than push patients or objects
  5. keep the spine in natural alignment while lifting or transferring
  6. get assistance when moving patients
  7. keep the weight to be lifted as close to the body as possible - ansANSWER:
  8. bend at the knees
  9. keep the spine in natural alignment while lifting or transferring
  10. get assistance when moving patients
  11. keep the weight to be lifted as close to the body as possible which body system controls balance? - ansANSWER: nervous which condition is a common consequence of osteoporosis?
  12. joint contractures
  13. pathologic fractures
  14. foot drop
  15. urinary stasis - ansANSWER:
  16. pathologic fractures which conditions are common effects of immobility? select all that apply.
  17. kidney stone formation
  18. increased muscle tone
  19. joint contractures
  20. diarrhea
  21. increased cardiac workload - ansANSWER:
  22. kidney stone formation
  23. joint contractures
  24. increased cardiac workload which conditions are diagnosed more frequently in infancy and childhood than in adulthood? select all that apply
  25. spina bifida
  26. osteoporosis
  27. osteoarthritis
  28. cerebral palsy
  29. rheumatoid arthritis - ansANSWER:
  30. spina bifida
  31. cerebral palsy which device is most appropriate for preventing foot drop in a patient on bed rest?
  1. the affected leg is advanced to the higher stair, followed by both crutches
  2. the unaffected leg is advanced to the higher stair, followed by both crutches
  3. both legs are advanced to the higher stair, followed by both crutches
  4. both crutches are advanced to the higher stair, followed by both legs. - ansANSWER:
  5. the unaffected leg is advanced to the higher stair, followed by both crutches which metabolic changes result from immobility? select all that apply
  6. decreased calcium blood levels
  7. negative nitrogen balance
  8. decrease in BMR
  9. decreased appetite
  10. increased muscle mass due to muscle protein anabolism - ansANSWER:
  11. negative nitrogen balance
  12. decreased BMR
  13. decreased appetite which method is the most likely means of transmitting infection between patients?
  14. exposure to another patient's cough
  15. sharing equipment among patients 3. disposing of soiled linen in a shared linen bag
  16. contact with a health-care worker's hands - ansANSWERS:
  17. contact with a health-care worker's hands which mineral supplement is most likely to be included in the medication list for a patient with osteoporosis?
  18. zinc
  19. calcium
  20. sodium
  21. iron - ans2. calcium which nursing actions are examples of data validation? select all that apply.
  22. asking the patient to describe a symptom by saying, "go on"
  23. asking the patient if he is having pain and then asking the patient to rate the severity
  24. obtaining a blood pressure value that is abnormal and asking the charge nurse to repeat the measurement
  25. assessing the patient's heart rate and comparing the value with the last value entered in the medical record
  26. observing a patient reading a teaching booklet and asking the patient if he has questions about its content - ansANSWER:
  27. obtaining a blood pressure value that is abnormal and asking the charge nurse to repeat the measurement
  28. assessing the patient's heart rate and comparing the value with the last value entered in the medical record which outcome statement identifies a reasonable short-term goal for a patient who is weak and has been immobilized in a supine position for 2 weeks?
  29. patient will ambulate with the assist of two caregivers three times within 24 hours
  1. patient will return to independent activities of daily living within 2 weeks
  2. patient will dangle at bedside with the assist of one caregiver three times within 24 hours
  3. patient will experience no falls within 1 month. - ansANSWER:
  4. patient will dangle at bedside with the assist of one caregiver three times within 24 hours which patients are most at risk for tachypnea? select all that apply.
  5. patient admitted with four rib fractures
  6. woman who is 9 months pregnant
  7. adult who has consumed alcoholic beverages
  8. adolescent awaking from sleep
  9. patient who regularly runs marathons - ansANSWERS:
  10. patient admitted with four rib fractures
  11. woman who is 9 months pregnant which physiologic changes are associated with immobility? select all that apply
  12. increased lung expansion
  13. calcium imbalance
  14. decreased BMR
  15. increased cardiac workload
  16. increased catabolism of protein - ansANSWERS:
  17. calcium imbalance
  18. decreased BMR
  19. increased cardiac workload
  20. increased catabolism of protein which questions would the nurse ask to assess the chronology of the patient's chief complaint of abdominal pain? select all that apply
  21. "how and when did the pain start?"
  22. "was the onset gradual or sudden?"
  23. "can you tell me more about your problem?"
  24. "can you show me where the pain is located?"
  25. " is the pain accompanied by any other problems or complaints?" - ansANSWER:
  26. "how and when did the pain start?"
  27. "can you tell me more about your problem?"
  28. "can you show me where the pain is located?" which statements are true about various patterns of respiration? select all that apply.
  29. apnea is the absence of respiration for a short time
  30. apnea is the increase in rate and depth of respiration
  31. kussmaul respiration is the increase in rate and depth of respiration
  32. kussmaul respiration is the period of apnea following periods of rapid and shallow breathing
  33. cheyne-stokes respiration is the period of apnea following a period of rapid and shallow breathing. - ansANSWERS: