Study Guide Cleaned PDF

**Chapter 1: Understanding Health Assessment** 2\. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to: a. Diagnose and treat patients. b. Identify normal and abnormal findings. c. Refer patients with abnormal findings. d....

**Chapter 1: Understanding Health Assessment** 2\. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to: a. Diagnose and treat patients. b. Identify normal and abnormal findings. c. Refer patients with abnormal findings. d. Counsel patients with psychosocial needs. 5\. A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age 48. The doctor recommended that this patient have a colonoscopy this year. This is an example of: a. Primary health prevention. b. Secondary health prevention. c. Tertiary health prevention. d. Primordial health prevention. 6\. A patient in the hospital puts on his call light and tells the person answering that he, "thinks he is running a fever and has stomach discomfort." You are the registered nurse in charge. What should you do? a. Ask the medical assistant to go to the patient's room and assess his complaints. b. Go check to see if the patient has an order for Tylenol for a fever. c. Page the resident on call immediately to assess the patient. d. Go to the patient's room and assess for fever and the epigastric discomfort. **Multiple Response** 11\. You are performing a health assessment on a 32-year-old female patient who reports, "feeling fatigued all the time." She states, "I have not had a physical in over 8 years because I did not have medical insurance." The patient will be having a physical today. What will be part of the health assessment? *Select all that apply.* a. Collecting data on past health. b. Collecting data on present health. c. Collecting data on significant other's health. d. Assessing factors influencing health. e. Performing a physical examination. **Completion** 12\. You are working with a patient as a copartner in care. The patient has multiple medical problems. Put the following steps of the nursing process in the correct order (1--5). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.) 1\. Planning 2\. Evaluation 3\. Assessment 4\. Implementation 5\. Diagnosis 14\. The four techniques of physical assessment include inspection, palpation, percussion, and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. **Chapter. 1 Answers** 2\. ANS: 2 5\. ANS: 2 6\. ANS: 4 11.ANS: 1, 2, 4, 5, 12 ANS: 35142 14\. ANS: auscultation **Chapter 2: Interviewing the Patient for a Health History** **Multiple Response** 1\. The nursing instructor is teaching a group of students the components of the health history interview. Which principles of behavior should the student remember when conducting a health assessment history? *Select all that apply.* a. Remain sensitive. b. Be nonjudgmental. c. Give the appearance only of being genuine. d. Demonstrate professional behaviors. e. Show indifference. 3\. A patient comes to the clinic for an annual examination. To prepare for the health history interview, the nurse knows to include which of the following components? *Select all that apply.* a. Reading the patient record as the health history is being conducted. b. Leaving the patient dressed until it is time to perform the physical assessment. c. Conducting the interview in a private place away from noise. d. Allowing a short, limited amount of time to conduct the interview. e. Standing at all times when talking to the patient. 6\. Communication is both verbal and nonverbal. The following are nonverbal visual cues to be aware of during an interview. *Select all that apply.* a. Slouching in the chair. b. Frowning. c. No eye contact. d. Gestures. e. Age-appropriate appearance. 7\. A patient and her husband arrive at the community health center for a follow-up assessment. The patient has recently had a stroke and is aphasiac. She understands what you are saying but is unable to talk. Which of the following nursing interventions should be followed? *Select all that apply.* a. Ask the husband the best way to communicate with his wife. b. Find a large blackboard to write your questions on. c. Offer the patient a white board or paper and pen. d. Speak loudly so the patient understands. e. Communicate one question or sentence at a time. 8\. Communication is a reciprocal conversation. Identify barriers to communication. *Select all that apply.* a. Asking too many questions. b. Leading the patient. c. Silence. d. Offering false reassurance. e. Stereotyping. 9\. As the nurse prepares for a patient interview he or she recalls that effective communication includes which of the following? *Select all that apply.* a. Avoid medical jargon. b. Be authoritative. c. Keep questions simple and clear. d. Stand over the patient. e. Avoid excessive note taking. 11\. The nurse is conducting a health history interview and suspects that the patient may have a hearing deficit. Which consideration is most appropriate for the nurse to make? a. Speak directly to the patient's significant other. b. Reduce any background noise in the room. c. Speak quickly and use short, simple sentences. d. Complete the health history as quickly as possible to reduce stress. 12\. The patient has disclosed a visual impairment to the nurse. Which is the priority action for the nurse to remember before starting the physical assessment? a. Speak clearly and loudly at all times during the assessment. b. Acknowledge the patient by putting a hand on his or her shoulder. c. Give short directions throughout the assessment. d. Ask the patient how much he or she can see. 13\. A patient's culture can influence the interview process. The nursing student recognizes that which of the following is true about how culture can influence the interview process? a. A patient may have different definitions and perceptions of health and illness. b. A patient cannot refuse to discuss personal matters out of concern for privacy. c. A patient may project his or her own cultural beliefs on the nurse. d. A patient may try to portray the cultural beliefs of the nurse. 14\. When conducting the interview, the nurse needs to determine the reliability of the data collected. Which primary source would be considered the most reliable for the health history information? a. The patient who is alert and oriented to person, place, and time. b. The significant other who is answering all the questions. c. The patient's medical record from the primary care provider. d. An interpreter who speaks the patient's native language. 15\. The nurse is preparing to conduct a health history on a patient and organizes the interview in a head-to-toe sequence. Which type of health history is the nurse going to conduct? a. Comprehensive b. Focused c. Problem-based d. Follow-up 16\. The nurse is preparing to conduct a health history on a patient seen in the health clinic 2 days ago. Which type of health history is the nurse going to conduct? a. Comprehensive b. Focused c. Problem-based d. Follow-up 17\. The nurse is preparing to conduct a health history on a patient being seen in the emergency room. Which type of health history is the nurse going to conduct? a. Comprehensive b. Focused c. Basic d. Follow-up 18\. While conducting a health history during admission to the medical floor, the nurse asks the patient, "Have you ever had surgery?" This question is an example of which type of communication technique? a. Open-ended question b. Closed-ended question c. Indirect question d. Clarification question 19\. The nursing student is learning how to use various therapeutic communication techniques. The student recognizes which of these as an example of confrontation? a. "You look angry." b. "This must be very hard for you." c. "Do you feel worried about your dog?" d. "How can I help you?" 20\. You are completing a health history on a 32-year-old woman who is reporting that, "she may have a problem using heroin and other drugs." You are being attentive to the patient's report and nonverbal cues. The patient is looking down as she is telling her story. What communication technique is the nurse demonstrating? a. Silence b. Respect c. Active listening d. Exploring 21\. A home health nurse is assessing a 94-year-old patient with a severe cognitive impairment. The daughter with whom the patient lives states that her mom only eats less than half of all her meals. What will you document? a. Patient is reliable. Cared for by her daughter. Eating half of her meals. b. Report by daughter. Eating 50% of her meals. Patient lives with her daughter. c. Patient is unreliable. Report by daughter. Patient is only eating less than 50% of each meal. d. Patient is unreliable. Eating about 50% of each meal. 23\. Which question or statement would be the best approach to elicit further information when conducting a health history interview? a. "Why didn't you go to the doctor when you began to have this pain?" b. "Are you feeling better now than you did during the night?" c. "Tell me more about what you think is causing your pain." d. "You should not wait to get medical help next time." 24\. A resident at an assisted living facility comes to the nurse's office and states, "My bowel movements have been fluctuating for the last 2 weeks." How should the nurse respond? a. "What do you mean by fluctuating?" b. "Why don't you use a laxative every night?" c. "When was the last time that you moved your bowels?" d. "Everyone experiences bowel problems as they age." 25\. During the summarization phase of the interview it is important to: a. Encourage the patient to tell his or her history of present illness. b. Complete documenting the data as told by the patient. c. Clarify the patient's report, needs, feelings, and concerns. d. Ask the patient if he or she has any questions. 26\. The nurse has completed a health history. Both objective and subjective information have been obtained during the assessment. Which is classified as subjective data? a. Patient appears sleepy. b. No distress noted. c. Abdomen is soft and nontender. d. Patient states she feels anxious and tense. 27\. You are assessing a patient who does not seem to understand your questions and explanations. What should be your next action? a. Continue on with the assessment. b. Speak loudly so the patient can hear you. c. Ask the patient if he or she understands what you are saying. d. Omit the explanations and continue with the assessment. 28\. A patient is having his annual physical examination. You are doing a health history related to male breasts. You ask the patient if he has ever palpated his breasts. He responds, "I cannot believe that you asked me that question. I am not a woman and cannot get breast cancer." The nurse responds, "You sound surprised. You don't think that men can get breast cancer?" What type of communication technique is the nurse using? a. Focusing b. Facilitation c. Reflecting d. Exploring 29\. Your patient reports that he thinks that he may have a problem with drinking too much beer. The nurse states, "So, do you drink about two beers every day?" What type of communication technique is this question? a. Leading the patient b. Transitional statement c. Clarification d. Exploring 30\. You are about to start the health history. The patient is present with his daughter. Which of the following priority steps should you take before you start the health history? a. Organize your thoughts prior to the assessment. b. Wash your hands in front of the patient. c. Obtain permission from the patient for the daughter to be present. d. Assess your professional appearance and demeanor. 31\. The patient just had abdominal surgery and reports that she is feeling bloated and crampy. The nurse inspects her abdomen and finds it to be bloated. The nurse tells the patient, "You will feel better tomorrow." This is an example of which communication technique? a. Respect b. Using clichés c. Giving opinions d. Using patronizing language 32\. The visiting nurse is going to start an interview at a patient's home. The patient is watching television. The patient is hard of hearing and reports that her left ear is her good ear. Which nursing intervention should take highest priority? a. Speak in simple, focused sentences. b. Ask to have the television volume turned down. c. Be descriptive when giving directions. d. Use drawings and a white board to ask questions. 33\. You are about to start an interview with the husband and wife present. The husband tells the nurse that his wife doesn't speak English well, and that he can interpret for her. Why is it not recommended to use family members as an interpreter during an assessment? a. A family member may be too objective when giving information. b. A family member may purposely omit information. c. A family member can never be trusted. d. A family member may share too much. 34\. Which consideration should the nurse recognize as priority when interviewing the patient? a. Gender b. Socioeconomic status c. Developmental level d. Education 37\. As you enter the examination room to start the health history interview, the patient immediately starts yelling at you because he waited 45 minutes in the waiting room. He is angry and upset. You should: a. Tell the patient to lower his voice and stop yelling. b. Put your hand on the patient's shoulder and tell him it will never happen again. c. Not argue with the patient and be empathetic. d. Tell the patient that you will be right back and go get the health-care provider. 38\. The three phases of the interview, in order, are: 1) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 2) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, and 3) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Chapt. 2 **Answers** **Multiple Response** 1\. ANS: 1, 2, 4 3\. ANS: 2, 3 6\. ANS: 1, 2, 3, 4 7\. ANS: 1, 2, 3, 5 8\. ANS: 1, 3, 5 9\. ANS: 1, 3, 5 11\. ANS: 2 12\. ANS: 4 13\. ANS: 1 14\. ANS: 1 15\. ANS: 1 16\. ANS: 4 17\. ANS: 2 18\. ANS: 2 19\. ANS: 1 20\. ANS: 3 21\. ANS: 3 23\. ANS: 3 24 ANS: 1 25\. ANS: 3 26\. ANS: 4 27\. ANS: 3 28\. ANS: 3 29\. ANS: 1 30\. ANS: 3 31\. ANS: 2 32\. ANS: 2 33\. ANS: 2 34\. ANS: 3 37\. ANS: 3 38\. ANS: introductory, working, summarization. **Chapter 3: Taking the Health History** **Multiple Choice** 12\. A patient arrives in the emergency department with a complaint of an injury at work. As part of the admission assessment, the nurse needs to determine how the injury occurred. What priority question or statement will the nurse ask to determine the cause of the injury? a. "Tell me how this injury occurred." b. "Do you think it is time to find a new job?" c. "Do you think your employer will pay your health-care costs?" d. "Will you continue to get paid even while you are injured?" 15\. A nurse has been assigned to care for a patient from a cultural background that he is not familiar with. He knows that it is important to provide culturally competent care to all of his patients. In order to do this, the nurse understands there are some important practices to follow, including: a. Telling the patient that you do not understand his culture and practices. b. Encouraging the patient to be open and share his beliefs, concerns, and practices with you. c. Telling the patient that due to a busy assignment, you do not have time to learn about his culture. d. Telling the patient there is only one meal option and the hospital does not have dietary options for other cultures. 17\. While performing a health history, the patient seems to be sad with a loss of interest in daily activities. The nurse wants to do a thorough assessment for depression. The nurse knows, in assessing the patient for depression, to ask which of the following questions? a. "Is it okay if we talk about your feelings of sadness?" b. "Many patients feel sad when they are in the hospital. Do you feel alone?" c. "Over the past 2 weeks have you felt down, depressed, or hopeless?" d. "You seem to be sad. Do you want me to get someone for you to talk to?" 19\. A patient's reason for seeking health care may focus on: a. The history of present health. b. The history of present illness. c. The presenting symptoms. d. All of the above. **Multiple Response** 23\. In assessing a patient's activities of daily living (ADLs) the nurse needs to ask the patient if he or she is independent in ADLs or if he or she needs assistance. The activities that the nurse will question the patient about include which of the following? *Select all that apply.* a. Sleeping b. Meal preparation c. Driving d. Dressing e. Bathing 25\. A 33-year-old female has arrived in the emergency department after being hit by a car. It is evident she will have a long recovery ahead of her. The nurse wants to be sure she has a support system in place. What questions will the nurse ask the patient to assess her support system? *Select all that apply.* a. "Does anyone else live with you?" b. "Tell me about your family and friends." c. "Do you think you will need to go to a rehab facility?" d. "Who is your support system?" e. "Who would you like on your visitor list?" 29\. The nurse is performing a mental health assessment on a 42-year-old male patient. As part of the mental health assessment, the nurse needs to assess the patient's orientation to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. 30\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ data are pieces of information specifically reported by the patient in a health history. **Chapter 3: Answers** 12\. ANS: 1 15\. ANS: 2 17\. ANS: 3 19\. ANS: 4 23\. ANS: 2, 3, 4, 5 29\. ANS: person, place, time, situation (in any order) Feedback: The mental health assessment is ongoing and assesses mental function, including whether a person is oriented to person (*What is your name?*), place (*Where are you right now? What is your address?*), time (*What is today's date? What season are we in?*), and situation (*What are you doing right now?)*. 30\. ANS. Subjective **Chapter 4: Assessing Nutrition and Anthropometric Measurements** 6\. A 22-year-old female patient is discussing her weight with her nurse and seems to be concerned about her present weight. Which of the following questions can the nurse ask to determine the patient's weight history? a. "Are you happy with your weight?" b. "What is your goal weight?" c. "We can talk about this later if you are uncomfortable." d. "Have you lost or gained weight?" 9\. A nutritional assessment is based on: a. Food intake, water intake, exercises, and caloric intake. b. Height, weight, and recent weight loss or gain. c. Physical examination, anthropometric measurements, laboratory data, and food intake. d. Food allergies, food availability, and height and weight. 19\. A nursing instructor is discussing individuals who are at risk for malnutrition with a nursing student. The instructor recognizes that the student needs further education if he indicates which of the following groups of individuals as being at risk for undernutrition? a. Alcoholics b. College students c. Elderly d. Individuals with chronic illness 22\. You are assessing an 89-year-old patient in a long-term care facility. The nursing aide reports to you that the patient states that he has no appetite and is only eating 50% of his meals. What will you document in the nursing note? a. Patient has anorexia and is eating less than 50% of his meals. b. Patient has anorexia and is eating only 50% of his meals. c. Patient has ageusia and is eating only 50% of his meals. d. Patient has dysgeusia and is eating less than 50% of his meals. 23\. While the patient is eating her meal you observe her having difficulty swallowing solid food. The medical term for difficulty swallowing is: a. Dysgeusia. b. Dysphasia. c. Dysphagia. d. Ageusia. 24\. You are performing a nutritional assessment through direct observation. The patient was given a half cup of mashed potatoes, a hamburger on a bun, and a half cup of string beans. He eats a quarter cup of the mashed potatoes, all of the hamburger, and all of the string beans. What would you document? a. Patient ate 90% of his meal. b. Patient ate greater than 80% of his meal. c. Patient ate less than 75% of his meal. d. Patient ate 50% of his meal. **Multiple Response** 27\. A patient's nutritional status can be influenced by many different factors including which of the following? *Select all that apply.* a. Economic considerations b. Number of fast-food restaurants c. Available transportation d. Cultural and ethnic influences e. Lack of knowledge about good nutrition 30\. Mr. Packard is a hospice patient. You are assessing his nutrition through direct observation. What should be assessed? *Select all that apply.* a. Amount of food eaten b. Difficulty swallowing c. Only the amount of fluids taken d. Ability to feed himself e. Ability of the aide to feed him **Chapter. 4 Answers** 6\. ANS: 4 9\. ANS: 3 19\. ANS: 2 22\. ANS: 2 23\. ANS: 3 24\. ANS: 2 27\. ANS: 1, 3, 4, 5 30\. ANS: 1, 2, 4 **Chapter 5: Assessment Techniques** **Multiple Response** 3\. A nurse is performing a general assessment. What is he or she assessing when performing light palpation? *Select all that apply.* a. Skin textures b. Masses c. Tenderness d. Abdominal organs e. Color 4\. What is the purpose of direct percussion? *Select all that apply.* a. To assess for tenderness. b. To assess borders of an organ. c. To assess density of tissue. d. To assess presence of fluid. e. To assess lung sounds. **Multiple Choice** 5\. A patient is complaining of shortness of breath and mild chest pain. You are about to start the focused assessment. What should be the nurse's first action? a. Auscultate lung sounds. b. Auscultate heart sounds. c. Wash hands in front of patient. d. Call for help immediately. 9\. You are assessing a patient's skin and note what appears to be a small, discolored lesion on the patient's right cheek. What would be your next nursing action? a. Turn up the fluorescent lighting to better evaluate the lesion. b. Document a small, discolored lesion on right cheek. c. Continue to assess the rest of the patient's skin. d. Reassess using tangential lighting. 10\. A patient comes to the urgent care center stating that he feels his left leg is swollen. A fundamental assessment guideline when inspecting his left leg is which of the following? a. Expose only the patient's left leg and keep his other leg unexposed. b. Compare the symmetry of body parts from one side to the other side. c. Using the ulnar surface of your hand, feel the temperature of the skin of his left leg. d. Measure the left leg to assess calf circumference. **Completion** 13\. Health assessment requires the collection of data to accurately and safely care for every patient. What is the correct sequence of assessment techniques that will provide objective assessment data? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) \_\_\_\_1. Palpation \_\_\_\_2. Auscultation \_\_\_\_3. Inspection \_\_\_\_4. Percussion 14\. The nurse enters the room of a patient and encounters a strong foul odor. This is an example of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ inspection. 15\. You are percussing over the posterior lobes of the lungs. The lungs are healthy and normal. The percussion sound of normal healthy lungs is called \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. **Chapter 5. Answers** **Multiple Response** 3\. ANS: 1, 2, 3 4\. ANS: 2, 3, 4 **Multiple Choice** 5\. ANS: 3 9\. ANS: 4 10\. ANS: 2 13\. ANS: 3142 14\. ANS: direct 15\. ANS: resonance **Chapter 6: General Survey and Assessing Vital Signs** 6\. A nurse is preparing a patient for a vital sign assessment. Which of the following questions should the nurse ask prior to taking the vital signs? a. "Have you eaten any salty foods today?" b. "Do you have any allergies, and if so, what type of reaction?" c. "Have you had any caffeine or smoked in the past 30 minutes?" d. "Have you exercised today?" 7\. A nurse is preparing to auscultate an apical heart rate on a patient as part of a vital sign assessment. The nurse knows the proper order to assess the apical heart rate is which of the following? 1\. Uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, warm stethoscope, auscultate heartbeat, count beats for 30 seconds (multiply by2), clean stethoscope with alcohol, explain technique. 2\. Explain technique, place diaphragm of stethoscope over clothes over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 30 seconds (multiply by 2). 3\. Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over right fifth intercostal space at midclavicular line, count beats for 30 seconds (multiply by 2), clean stethoscope with alcohol. 4\. Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 60 seconds, clean stethoscope with alcohol. 11\. A nurse is assessing whether a patient is alert and oriented as part of assessing the patient's level of consciousness. The nurse knows that all of the following are checked to see if a patient is alert and oriented EXCEPT: a. Time. b. Place. c. Speech. d. Person. 12\. A nurse is preparing to take an oral temperature on a patient. The nurse understands that the patient needs to wait 30 minutes to take an oral temperature if the patient: a. Understands and follows directions. b. Is able to breathe through the nose. c. Has an altered mental status. d. Has had hot or cold food or drink in the last 30 minutes. 13\. A patient arrives for a physical assessment and is complaining of not feeling well. The nurse begins with a general survey and assessing vital signs. The nurse is concerned that the patient has orthostatic hypotension due to the patient complaining of: a. Alteration in mental status and forgetfulness. b. Dizziness and feeling lightheaded with position changes. c. Gastrointestinal upset, nausea, and vomiting. d. Feeling cold, weak, and shivering. 17\. A female patient, age 48, comes to the clinic with complaints of dizziness and a frontal headache. She tells you she is under a lot of stress because her husband was recently laid off. She is 5\'4\" and weighs 150 lb. You take her blood pressure and it is 178/100. When you tell her the blood pressure reading she says, "T*his cannot be right! I usually run 100/60*." What should be your next action? a. Tell the patient that stress can raise blood pressure. b. Wait 2 minutes and retake the blood pressure in the other arm. c. Call in the healthcare provider to retake the blood pressure. d. Document the blood pressure as high. 18\. You are caring for a patient with traumatic brain injury. The healthcare provider has ordered rectal temperatures daily. How far should you insert the rectal probe into the anal canal? a. About 0.50 inch b. About 0.75 inch c. About 1.0 inch d. About 1.5 inches 19\. You are assessing a 78-year-old hospice patient who has end stage lung cancer. Which of the following findings would indicate an acute decline in the patient's health status? a. Temporal temperature 99.8°F, pulse 82, irregular, amplitude +2, RR 22 b. Temporal temperature 100.8°F, pulse 90, regular, amplitude 2+, RR 20 c. Tympanic temperature 100.1°F, pulse 60, irregular, amplitude 3+, RR 18 d. Tympanic temperature 97°F, pulse 106, irregular, amplitude 1+, RR 26 20\. A 23-year-old client is being seen at the university health clinic for chest pain. The nurse has gathered the following assessment data: temperature 99.2°F (tympanic), pulse 90 (apical), regular respirations 28, blood pressure 144/84 (left arm). Which assessment data should be of greatest concern to the nurse? a. Temperature of 99.2°F b. Pulse 90 c. Respirations 28 d. Blood pressure 144/84 **Multiple Response** 24\. You are performing the general survey as part of the physical assessment. Which of the following observations are considered part of the general survey? *Select all that apply.* a. Body structure b. Patient's hygiene c. Vital signs d. Appears stated age e. Appears healthy 27\. Rectal temperatures are considered to be an accurate route for measuring core temperature. Rectal temperatures are contraindicated in which of the following patients? *Select all that apply.* a. Patients who have had rectal surgery b. Patients with cardiac disease c. Patients with diarrhea d. Patients who refuse a rectal temperature e. Patients who are immobile 31\. Hypertension (coronary heart disease) is a growing health problem in the United States. Which of the following factors can affect blood pressure? *Select all that apply.* a. Obesity b. Family history c. Alcohol consumption of three or more drinks per day d. Stress e. Diets high in magnesium **Chapter 6 Answers** 6\. ANS: 3 7\. ANS: 4 11\. ANS: 3 12\. ANS: 4 13\. ANS: 2 17\. ANS: 2 18\. ANS: 3 19\. ANS: 4 20\. ANS: 3 **Multiple Response** 24\. ANS: 1, 2, 4, 5 27\. ANS: 1, 2, 3 31\. ANS: 1, 2, 3, 4 **Chapter 7: Assessing Pain** **Multiple Choice** 1\. The nurse is assessing an alert patient who just had surgery several hours ago. He is awake and complaining of pain. What is the nurse's next action? a. Ask the patient what pain medication he prefers. b. Assess the patient's self-report of pain. c. Administer pain medication as ordered. d. Use distraction therapy to alleviate pain. 3\. A diabetic patient states the pain, "feels like needles and stings my feet. I also have numbness and tingling sensations." The nurse would describe this as: a. Neuropathic pain. b. Somatic pain. c. Visceral pain. d. Colicky pain. 4\. Which question or statement will provide the nurse with the most information about the patient's pain? a. "Are you in pain?" b. "Have you ever had pain?" c. "What is your level of pain on the numerical scale?" d. "Describe the pain you are experiencing." 6\. A patient fell off a ladder while painting his ceiling and hurt his lower back. He is now complaining of a burning, aching pain that is shooting down his leg. The nurse documents this as which type of pain? a. Phantom limb syndrome b. Psychogenic pain c. Radiating pain d. Referred pain 9\. The patient's family reports to the staff nurse that the patient is having a lot of pain. What is the nurse's best action? a. Medicate the patient for pain per the physician's order. b. Go to the patient's room and assess the patient's pain. c. Access the electronic medical record and determine when the patient last had pain medication. d. Tell the family you will reevaluate the patient when pain medications are due. 15\. The nurse is assessing a patient who states she has a pain level of "8." The patient is laughing and talking on the phone. What should the nurse do next? a. Reassess the level of pain to obtain a pain score that matches the patient's actions. b. Do nothing as this is an acceptable level of pain for this patient. c. Medicate the patient per healthcare provider orders, if time appropriate. d. Notify the healthcare provider of the patient's pain level. 16\. What does the abbreviation OPQRST represent? a. Onset, pain, quality, relieving, starting, treatment b. Original, particular, qualify, resting, standing, total c. Onset, provocation, quality, radiation, severity, timing d. Onset, pulsing, quota, realization, sensorium, temperature 17\. Which question would you ask a patient to assess the "P" (provocation of pain) in the OPQRST method of pain assessment?" a. "What causes the pain?" b. "What does the pain feel like?" c. "What symptoms do you have with the pain?" d. "Where do you feel the pain?" 18\. Which statement is true regarding pain assessments? a. Only one type of pain assessment is best to use with the patient to prevent confusion. b. The patient's self-report of pain is the only valid pain assessment. c. Combining pain assessment validations is more reliable than just using one type of assessment. d. Teaching the nurse one pain scale to care for patients is the most essential. **Multiple Response** 23\. Which are factors that can affect the pain experience? *Select all that apply.* a. Age of patient b. Gender c. Cultural background d. Birth order e. Previous pain experience 24\. You are starting the health history on a patient who states he has right hip pain. Which are examples of nonverbal body language indicative of pain that you may observe during the interview? *Select all that apply.* a. Rating pain a 7 out of 10 b. Facial grimacing c. Moaning d. Protective guarding e. Rapid breathing 28\. The patient has chronic pain from rheumatoid arthritis. Which are functional effects of chronic pain? *Select all that apply*. a. Inability to work b. Anger c. Inability to perform activities of daily living (ADLs) d. Disability e. Anxiety 29\. The patient has sharp and localized somatic pain. This type of pain most often originates in which of the following? *Select all that apply*. a. Lungs b. Organs c. Muscle d. Joints e. Bones **Chapter 7: Answers** **Multiple Choice** 1\. ANS: 2 3\. ANS: 1 4\. ANS: 4 6\. ANS: 3 9\. ANS: 2 15\. ANS: 3 16\. ANS: 3 17\. ANS: 1 18\. ANS: 3 **Multiple Response** 23\. ANS: 1, 2, 3, 5 24\. ANS: 2, 3, 4, 5 27\. ANS: 2, 3, 5 28\. ANS: 1, 3, 4 29\. ANS: 3, 4, 5