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conduct the interview being positioned at eye level maintaining a distance of 1.5 m.
When preparing the physical setting for an interview, the interviewer should
set the room temperature to 15°C.
reduce noise by turning down the volume on the television or radio.
conduct the interview being positioned at eye level maintaining a distance of 1.5 m.
stand next to the patient to convey a professional demeanour.
7 years
Parents or caregivers accompany children to the health care setting. At what age does the interviewer start asking the child directly about his or her presenting symptoms?
5 years
7 years
9 years
11 years
“Tell me what you mean by ‘bad blood’.”
Which of the following statements, if made by the interviewer, would be an appropriate response?
“I know just how you feel.”
“If I were you, I would have the surgery.”
“Why did you wait so long to make an appointment?”
“Tell me what you mean by ‘bad blood’.”
helps the patient understand personal feelings in relation to his or her verbal message.
While discussing the treatment plan, the nurse infers that the patient is uncomfortable about asking the health care provider for a different treatment because of fear of the health care provider’s reaction. In this situation, the nurse’s verbal interpretation
affects the nurse–physician relationship.
impedes further discussion.
helps the patient understand personal feelings in relation to his or her verbal message.
helps the nurse understand his or her own feelings in relation to the patient’s verbal message.
avoidance language.
The use of euphemisms to avoid reality or to hide feelings is known as
distancing language.
sympathetic language.
avoidance language.
ethnocentric language.
use short, simple, concrete sentences.
When addressing a pre- school-aged child during the interview, the health care provider should
ask the child, before asking the caregiver, about symptoms.
use nonverbal communication.
use short, simple, concrete sentences.
use detailed explanations.
Infants
Nonverbal communication is the primary form of communication for which group of individuals?
Infants
Preschoolers
Adolescents
Older adults
empathy
Viewing the world from another person’s inner frame of reference is called
reflection.
empathy.
clarification.
sympathy.
“Tell me about your pain.”
An example of an open-ended question or statement is
“Tell me about your pain.”
“On a scale of 1 to 10, how would you rate your pain?”
“I can see that you are quite uncomfortable.”
“You are upset about the level of pain, right?”
“Mr. Jones, I want to ask you some questions about your health so that we can plan your care.”
The most appropriate introduction to start an interview with an older adult patient is
“Mr. Jones, I want to ask you some questions about your health so that we can plan your care.”
“David, I am here to ask you questions about your illness; we want to determine what is wrong.”
“Mr. Jones, is it okay if I ask you several questions this morning about your health?”
“Because so many people have already asked you questions, I will just get the information from the chart.”
Reliability of informant
Which of the following is included in documenting a history source?
Appearance, dress, and hygiene
Cognition and literacy level
Documented relationship of support systems
Reliability of informant
aggravating factors.
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
the patient’s perception of pain.
the nature or character of the headache.
aggravating factors.
relieving factors.
what the patient says about himself or herself.
The health history collects subjective data, which comprise
findings from the physical examination.
laboratory values.
what the patient says about himself or herself.
results of diagnostic tests.
an evaluation of past and present health state of each body system.
The review of systems in the health history is
an evaluation of past and present health state of each body system.
a documentation of the problem as perceived by the patient.
a record of objective findings.
a short statement of general health status.
the presence or absence of all symptoms under the system heading.
When recording information for the review of systems, the interviewer must document
physical findings, such as skin appearance, to support historical data.
“negative” under the system heading.
the presence or absence of all symptoms under the system heading.
objective data that support the history of present illness.
education, financial status, and value-belief system.
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include
education, financial status, and value-belief system.
exercise and activity, leisure activities, and level of independence.
family role, interpersonal relations, social support, and time spent alone.
stressors, coping mechanisms, and any changes in past year.
symptoms.
PQRSTU is a mnemonic that helps the clinician remember to address characteristics specific to
intimate partner violence.
substance use.
symptoms.
the ability to perform activities of daily living (ADLs).
rephrase the same questions later in the interview.
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
review previous medical records.
rephrase the same questions later in the interview.
ask the patient if there is someone who could verify information.
call a family member to confirm information.
interview the youth alone, with the parent(s) waiting in the waiting area.
When taking the health history from an adolescent, the interviewer should
ask about violence and abuse before asking about alcohol and drug use.
have at least one parent present during the interview.
interview the youth alone, with the parent(s) waiting in the waiting area.
ask about the use of condoms.
Nutritional data
What information is included in greater detail when taking a health history on an infant?
Nutritional data
History of present illness
Family history
Environmental hazards
allow the child to sit on the parent’s lap.
To examine a toddler, the nurse should
allow the child to sit on the parent’s lap.
remove the child’s clothing at the beginning of the examination.
ask the child to decide whether parents or siblings should be present.
perform the assessment from head to toes.
identify abdominal contents.
Deep palpation is used to
identify abdominal contents.
evaluate surface characteristics.
elicit deep tendon reflexes.
determine the density of a structure.
the intensity (soft or loud) of sound.
Amplitude is
the intensity (soft or loud) of sound.
the length of time the note lingers.
the number of vibrations per second.
the subjective difference in a sound’s distinctive overtones.
temperature.
The dorsa of the hands are used to determine
vibration.
temperature.
an organ’s position.
fine tactile discrimination.
fingertips.
Fine tactile discrimination is best achieved with the
opposition of the fingers and the thumb.
fingertips.
back of the hands and fingers.
base of the fingers.
internal structures of the eye.
An examination of the fundus is an examination of the
inner ear.
pharynx.
internal structures of the eye.
nasal turbinates.
Basing the pace of the examination on the patient’s needs and abilities
Which of the following is considered when preparing to examine an older adult?
Basing the pace of the examination on the patient’s needs and abilities
Avoiding physical touch to offset making the older adult uncomfortable
Being aware that loss will result in poor coping mechanisms
That confusion is a normal, expected finding in an older adul
strikes the stationary finger at the distal interphalangeal joint.
When performing percussion, the examiner
strikes the flank area with the palm of the hand.
strikes the stationary finger at the distal interphalangeal joint.
strikes the stationary finger at the proximal interphalangeal joint.
taps fingertips over bony processes.
review the findings with the patient.
At the end of the examination, the examiner should
complete the documentation before leaving the examination room.
have the findings confirmed by another provider.
compare objective and subjective data for discrepancies.
review the findings with the patient.
The patient is admitted with a methicillin-resistant Staphylococcus aureus infection.
When would the nurse use second-tier precautions in addition to routine practices?
The patient is admitted with a leg fracture.
The patient is admitted with a methicillin-resistant Staphylococcus aureus infection.
The patient is a postpartum mother.
The patient is admitted for heart surgery.
physical appearance, body structure, mobility, and behaviour.
The general survey consists of four distinct areas. These areas include
mental status, speech, behaviour, and mood and affect.
gait, range of motion, mental status, and behaviour.
physical appearance, body structure, mobility, and behaviour.
level of consciousness, personal hygiene, mental status, and physical condition.
waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
A common error in blood pressure measurement includes
taking the blood pressure in the arm positioned at the level of the heart.
waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
deflating the cuff by about 2 mm Hg per heartbeat.
using a blood pressure cuff whose bladder length is 80% of the arm circumference.
at the first encounter.
Data collection for the general survey begins
at the first encounter.
at the beginning of the physical examination.
while taking vital signs.
during the mental status examination.
augments Korotkoff’s sounds during blood pressure measurement.
The Doppler technique
is used to assess the apical pulse.
augments Korotkoff’s sounds during blood pressure measurement.
provides an easy and accurate measure of the diastolic pressure.
measures arterial oxygenation saturation.
provides an accurate measurement of core body temperature.
The tympanic membrane thermometer
provides an accurate measurement of core body temperature.
senses the infrared emissions of the cerebral cortex.
is not used in unconscious patients.
accurately measures temperature in 20 to 30 seconds.
caused by excess adrenocorticotropic hormone (ACTH) production by the pituitary gland.
Endogenous obesity is
caused by inadequate secretion of cortisol by the adrenal glands.
caused by excess adrenocorticotropic hormone (ACTH) production by the pituitary gland.
characterized by evenly distributed excess body fat.
a result of excessive secretion of growth hormone in adulthood.
count for 30 seconds after completing a pulse assessment, and multiply by 2.
To perform an accurate assessment of respirations, the examiner should
inform the person of the procedure and count for 1 minute.
count for 15 seconds while keeping fingers on the pulse, and multiply by 4.
count for 30 seconds after completing a pulse assessment, and multiply by 2.
assess respirations for a full 2 minutes if an abnormality is suspected.
stated age.
Physical appearance includes statements that compare appearance with
mood and affect.
stated age.
gait.
nutrition.
bradycardia.
An adult patient’s pulse is 46 beats per minute. The term used to describe this rate is
tachycardia.
bradycardia.
weak and thready.
sinus arrhythmia.
Anxiety
The nurse records that the patient’s pulse is 3+, or “full and bounding.” Which of the following could be the cause?
Dehydration
Shock
Bleeding
Anxiety
afferent fibres.
Pain signals are carried to the central nervous system by way of
perception.
afferent fibres.
modulation.
referred pain.
Patient’s self-report
Which of the following is the most reliable indicator for pain?
Magnetic resonance imaging (MRI) results
Patient’s self-report
Tissue enzyme levels
Blood drug levels
Infants have the same capacity for pain as do adults.
Which of the following is true regarding pain in children?
Infants have the same capacity for pain as do adults.
Preverbal infants do not remember pain.
Children older than 2 years of age are able to accurately rate pain intensity.
Children will exaggerate their descriptions of pain in the presence of a health care provider.
Pain signals move from the site of origin to the spinal cord.
What occurs during transduction (the first phase of nociceptive pain)?
Pain signals move from the site of origin to the spinal cord.
The pain impulse moves from the spinal cord to the brain.
The brain interprets the pain signal.
Chemical mediators are neutralized, decreasing the perception of pain.
Acute
What type of pain is short and self-limiting, and dissipates after the injured tissue has healed?
Chronic
Persistent
Acute
Malignant
processing of the pain message.
Neuropathic pain implies an abnormal
degree of pain interpretation.
processing of the pain message.
transmission of pain signals.
modulation of pain signals.
Bones and joints
What is the source of deep somatic pain?
Skin and subcutaneous tissues
Bones and joints
Pancreas
Intestine
Genetics
Which of the following has been found to influence pain perception in women?
Age
Genetics
Parity
Weight
nociceptors.
Specialized nerve endings that are designed to detect painful sensations are
synapses.
dorsal horns.
nociceptors.
C fibres.
administer prescribed pain medication.
An intubated sedated patient has a score of 7 on the Critical-Care Pain Observation Tool. The nurse should
reassess the pain level in 3 to 4 hours.
administer prescribed pain medication.
confirm the pain level with vital signs.
use only nonpharmacological pain relief interventions.
Drug reactions
While the nurse is taking the health history, the patient complains of pruritus. What is a potential cause of this symptom?
Excessive bruising
Hyperpigmentation
Diaphoresis
Drug reactions
purpura.
A flat macular hemorrhage is called a(n)
purpura.
ecchymosis.
petechiae.
hemangioma.
The skin is a first line of defense to protect you against microorganisms and injury.
A nursing student has been assigned to teach grade 4 students about the importance of caring for their skin. Which of the following should be included while discussing the skin?
The skin is the body’s second largest organ system.
The skin is not part of regulating temperature.
The skin is not waterproof.
The skin is a first line of defense to protect you against microorganisms and injury.
temperature regulation.
Functions of the skin include
production of vitamin C.
temperature regulation.
the production of new cells by melanocytes.
the secretion of a drying substance called sebum.
The patient is at very high risk for skin tears, skin breakdown, and/or the development of pressure sores.
A 75-year-old hospitalized patient with limited mobility, activity, and nutrition scores a 7 on the Braden Risk Assessment Scale. What does this indicate?
The patient is at risk for malignant melanoma.
The patient has severe cognitive impairment.
The patient is at very high risk for skin tears, skin breakdown, and/or the development of pressure sores.
The patient has pain that is greater than moderate in severity.
Zosteriform
Which of the following terms refers to a linear skin lesion that runs along a nerve route?
Zosteriform
Annular
Polycyclic
Shingles
shape, contour, consistency, and colour.
The components of a nail examination include
shape, contour, consistency, and colour.
colour, texture, distribution, and lesions.
clubbing, pitting, and grooving.
colour, texture, temperature, and moisture.
conjunctivae.
To determine if a dark-skinned patient is pale, the nurse should assess the colour of the
conjunctivae.
ear lobes.
elbows.
skin in the antecubital space.
urticaria.
An example of a primary lesion is a(n)
erosion.
ulcer.
urticaria.
port-wine stain.
erosion.
As cooped-out, shallow depression in the skin is called a(n)
ulcer.
excoriation.
fissure.
erosion.
cephalhematoma.
Bleeding into the periosteum during birth is known as
caput succedaneum.
craniosynostosis.
moulding.
cephalhematoma.
premature closure of the sutures.
Craniosynostosis is a severe deformity caused by
premature closure of the sutures.
increased intracranial pressure.
a localized bone disease that softens, thickens, and deforms bone.
excess growth hormone or a deficit in thyroid hormone.
fetal alcohol syndrome.
Narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia are characteristic of
Down’s syndrome.
fetal alcohol syndrome.
chronic childhood allergies.
hydrocephalus.
extend their heads and jaws forward.
Kyphosis of the spine is common with aging. To compensate, older adults will
shift their centre of gravity.
extend their heads and jaws forward.
stiffen their gait.
shuffle.
Alcohol consumption may precipitate the onset of cluster or migraine headaches.
Which of the following statements related to aggravating symptoms or triggers of headaches is accurate?
Alcohol consumption may precipitate the onset of cluster or migraine headaches.
Certain foods, such as chocolate or cheese, may precipitate the onset of tension headaches.
Premenstrual hormonal fluctuations may precipitate the onset of cluster headaches.
Poor posture may trigger a migraine headache.
Mandible
Most facial bones articulate at a suture. Which facial bone articulates at a joint?
Nasal bone
Mandible
Zygomatic bone
Maxilla
myxedema.
severe deficiency of thyroid hormone leading to nonpitting edema, coarse facial features, dry skin, and dry coarse hair is known as
Parkinson’s syndrome.
Cushing’s syndrome.
myxedema.
Graves’ disease.
“I have never had a headache like this before; it is so bad I can’t function.”
Which of the following statements describing a headache would warrant an immediate referral?
“This is the worst migraine of my life.”
“This is the worst headache I’ve had since puberty.”
“I have never had a headache like this before; it is so bad I can’t function.”
“I have had daily headaches for years.”
Bell’s palsy.
Your patient has right-sided facial paralysis, and cannot wrinkle their forehead, raise their right eyebrow, close their right eye, whistle, or show their teeth on the right side. These findings indicate
cerebral vascular accident (stroke).
Bell’s palsy.
Cushing’s syndrome.
Parkinson’s syndrome.
right pneumothorax.
A patient is admitted to the emergency department after a motor vehicle accident. The trachea is deviated to the left side. This finding is characteristic of
right pneumothorax.
aortic arch aneurysm.
right pleural adhesion.
right-sided atelectasis.
rectus; oblique
The extraocular muscles consist of four straight or ________ muscles and two slanting or ______ muscles.
palpebral; conjugate
superior; inferior
rectus; oblique
rectilinear; diagonal
optic chiasm.
he location in the brain where optic nerve fibres from the temporal fields of vision cross over is identified as the
optic chiasm
fovea centralis.
optic disc.
choroid.
Males of European descent between ages 4 and 8 years
Which of the following groups of individuals need to be tested for colour blindness (colour deficiency)?
Males of Indigenous descent between ages 10 and 15 years
Males of European descent between ages 4 and 8 years
Females of Asian descent between ages 3 and 6 years
Females of European descent between ages 4 and 8 years
The larger the denominator, the poorer is the vision.
Which of the following statements is true in regard to the results obtained from use of the Snellen chart?
The smaller the denominator, the poorer is the vision.
The larger the denominator, the poorer is the vision.
The larger the numerator, the better is the vision.
The smaller the numerator, the poorer is the vision.
refracting medium.
The lens of the eye functions as a
refracting medium.
mediator of light.
sensory facilitator.
controller of intraocular pressure.
ectropion
With aging the lower eyelid becomes loose, rolls outward and does not approximate to the eyeball. This condition is identified as
entropion.
chalazion.
ectropion.
blepharitis.
creamy yellow-orange to pink.
The normal colour of the optic disc is
red.
creamy pink.
creamy yellow-orange to pink.
creamy red to yellow-orange.
The covered eye maintains its position when uncovered.
Which of the following is an expected response on the cover-uncover test?
The covered eye moves into a relaxed position.
The covered eye maintains its position when uncovered.
The uncovered eye is unable to maintain its gaze on a fixed object.
The covered eye jumps to re-establish fixation when it is uncovered.
A unilateral, small, regular pupil that reacts to light and accommodation
Which of the following findings is associated with Horner’s syndrome?
Bilateral miosis
Bilateral mydriasis
A unilateral, small, regular pupil that reacts to light and accommodation
A unilateral dilated pupil with no reaction to light or accommodation
Macular degeneration
Decreased vision in the older adult may be caused by which of the following conditions?
Macular degeneration
Arcus senilis
Fixation
Presbyopia
identification and location of the direction of the sound.
Binaural interaction at the level of the brain stem permits
interpretation of sound.
identification and location of the direction of the sound.
amplification of sound.
direction of sound toward the appropriate conduction pathway.
Frequently asking to have the questions or statements repeated
Which of the following behaviours demonstrated by an individual may be indicative of hearing loss?
Not looking at the examiner when being questioned
Frequently asking to have the questions or statements repeated
Talking in a high-pitched voice
Speaking slowly with well-articulated consonants
An 18-month-old infant who has had three episodes of ear infections in a 5-month period
Which of the following is at risk of recurrent otitis media (OM)?
An 18-month-old infant who lives with a smoker
A 2-year-old child who has had two ear infections in the past 6 months
A 6-month-old infant who has a sibling who had tubes inserted at age 3 years
An 18-month-old infant who has had three episodes of ear infections in a 5-month period
auricle.
The external structure of the ear is identified as the
auricle.
atrium.
atrophy.
aura.
equilibrium.
The labyrinth of the inner ear is responsible for maintaining the body’s
binaural interaction.
air conduction.
equilibrium.
pressure equalization.
whiter than that of a younger adult.
en an otoscope examination is performed on an older adult, the tympanic membrane may be
pinker than that of a younger adult.
thinner than that of a younger adult.
whiter than that of a younger adult.
more mobile than that of a younger adult.
Audiometer test
Which of the following tests provides a precise quantitative measure of hearing?
Tuning fork tests
Romberg test
Audiometer test
Whispered voice test
horizontal
he position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope.
horizontal
vertical
perpendicular
oblique
bulging, with a distinct red colour.
The tympanic membrane of a child with acute OM would be
flat and slightly pulled in at the centre.
intact and mobile.
bulging, with a distinct red colour.
shiny and translucent, with a pearly grey colour.
scarring from recurrent ear infections.
If the tympanic membrane has white, dense areas, the examiner suspects
perforation resulting from a ruptured tympanic membrane.
scarring from recurrent ear infections.
serous fluid from serous OM.
a fungal infection.
bright red and swollen.
The nasal mucosa of an individual with rhinitis would be
moist and pink.
swollen, boggy, and grey.
bright red and swollen.
pale with bright red bleeding.
Hyperthyroidism
The examiner notices a fine tremor when the patient sticks out their tongue. What disorder is consistent with this finding?
Hyperthyroidism
Diabetic ketoacidosis
Halitosis
Alcoholism
“Do you experience nosebleeds?”
Which of the following questions would the examiner ask to determine whether an individual has epistaxis?
“Do you have any difficulty swallowing?”
“Have you ever noticed any unusual lesions on the inside of your mouth?”
“Do you experience nosebleeds?”
“Do you experience a runny nose frequently?”
an ulcer or sore that does not heal.
An early sign of oral cancer is
a white, cheesy, curdlike patch on the buccal mucosa and tongue.
pain.
an ulcer or sore that does not heal.
small isolated white/yellow papules on the mucosa of the cheeks, tongue, and lips.
Down’s syndrome.
An enlarged tongue (macroglossia) may accompany
cleft palate.
black, hairy tongue.
Down’s syndrome.
fissured tongue.
cleans and protects the mucosa.
In addition to initiating digestion of food, saliva also
augments taste sensation.
protects the mucosa from caustic substances.
inhibits overgrowth of bacteria in the mouth.
cleans and protects the mucosa.
lighten the weight of the skull bones.
One of the purposes of the paranasal sinuses is to
lighten the weight of the skull bones.
warm and moisten the inspired air.
amplify sound.
augment the sensory sensation of smell.
Stensen’s duct.
The parotid gland’s duct that opens into the mouth opposite the second molar is
Wharton’s duct.
the salivary duct.
Stensen’s duct.
the sublingual duct.
Frontal
Which of the following pairs of sinuses is absent at birth, is fairly well developed between ages 7 and 8 years, and is fully developed after puberty?
Maxillary
Frontal
Sphenoid
Ethmoid
Use of anticholinergic medications
What is the major cause of decreased saliva production in the older adult?
Use of anticholinergic medications
Normal aging process
Decreased fluid intake
Diminished sense of taste and of smell
Note 
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