HA Application 1 Questions

The nurse receives report on four patients. Which patient should be assessed FIRST? A. Patient asking how to manage a new low-sodium diet B. Patient reporting sudden difficulty breathing C. Patient reporting acute postoperative pain rated 8/10 D. Patient whose spouse is having difficulty coping

B. Sudden difficulty breathing. Breathing is a FIRST-level priority. Acute pain is SECOND-level, while education and family coping are THIRD-level.

The nurse identifies four problems during assessment. Which should be addressed SECOND? A. Obstructed airway B. New acute confusion C. Need for discharge education D. Difficulty coping with hospitalization

B. New acute confusion. A change in mental status is a SECOND-level priority. An airway problem is FIRST-level, while education and coping are THIRD-level.

Which findings represent SECOND-level priorities? Select all that apply. A. Acute pain B. Abnormal laboratory value requiring attention C. Need for medication teaching D. New mental status change E. Family coping problem

A, B, D. Acute pain, abnormal laboratory findings requiring attention, and mental status changes are SECOND-level priorities. Education and family coping are THIRD-level.

A nurse collects a patient's symptoms, vital signs, physical examination findings, and laboratory results. The nurse then groups related findings together. Which part of clinical reasoning is the nurse demonstrating? A. Implementation B. Data clustering C. Evaluation D. Health promotion

B. Data clustering. Clinical reasoning involves recognizing cues, collecting data, grouping related findings, interpreting patterns, and developing hypotheses.

After clustering assessment findings, the nurse identifies several possible explanations for the patient's problem. Which clinical reasoning action is occurring? A. Generating hypotheses B. Implementation C. Documentation D. Termination

A. Generating hypotheses.

A nurse chooses an assessment approach supported by research, considers personal clinical experience, and discusses the patient's preferences before proceeding. Which concept is best demonstrated? A. Reflection B. Evidence-based clinical decision-making C. Focused assessment D. Objective documentation

B. Evidence-based clinical decision-making integrates evidence, clinical expertise and assessment, and patient preferences and values.

A novice nurse collects every possible piece of information without recognizing which findings are most relevant. An experienced nurse immediately focuses on findings related to the patient's current problem. Which concept best explains the difference? A. Subjective versus objective data B. Novice versus expert practice C. Comprehensive versus focused history D. Inspection versus palpation

B. Novice versus expert practice. The expert is better able to recognize relevant data and connect findings with underlying pathology.

After completing a difficult assessment, a student reviews what went well, identifies what was missed, and considers how to improve the next assessment. Which concept is demonstrated? A. Percussion B. Reflection C. Diagnosis D. Validation

B. Reflection. Reflection during or after practice supports critical thinking and improvement.

A patient says, "I don't want that assessment performed that way. Is there another option?" Which response best reflects evidence-based practice? A. "Research says this is the best method, so we have to use it." B. "Whatever you want is fine." C. "Let's consider the evidence, your preferences, and appropriate alternative assessment methods." D. "I'll perform whichever technique I personally prefer."

C. Evidence-based practice considers evidence, clinical expertise and assessment, and patient preferences and values.

A nurse is preparing to examine a patient. Which actions promote an effective physical examination? Select all that apply. A. Provide adequate lighting B. Explain what will happen C. Expose the entire patient throughout the examination D. Organize the examination to minimize position changes E. Provide privacy

A, B, D, E. The nurse should provide lighting, explanations, privacy, and organize the examination efficiently. Only the area being examined should be exposed.

The nurse wants to assess a patient's skin temperature. Which technique is most appropriate? A. Palpate with fingertips B. Palpate with the dorsal surface of the hand C. Percuss the skin D. Use the stethoscope diaphragm

B. The dorsal surface of the hand is appropriate for assessing temperature.

A nursing student is auscultating a low-pitched sound. Which action requires correction? A. Using the bell B. Placing the stethoscope on the patient's skin C. Using the diaphragm specifically because the sound is low-pitched D. Maintaining a quiet environment

C. Low-pitched sounds are assessed with the bell; the diaphragm is used for high-pitched sounds.

Which assessment requires percussion? A. Observing skin color B. Determining underlying tissue density C. Comparing skin temperature D. Listening to a body sound

B. Percussion involves tapping to obtain information about underlying structures such as density, organ location or size, masses, and tenderness or inflammation.

The nurse removes gloves after assessing an open skin lesion. Which action should occur next? A. Document the lesion B. Perform hand hygiene C. Apply another pair of gloves D. Continue the examination

B. Perform hand hygiene after removing gloves.

A nurse moves from a contaminated area of the patient's body to a clean area. Which action is appropriate? A. Continue without hand hygiene because it is the same patient B. Perform appropriate hand hygiene before moving to the clean site C. Only perform hand hygiene if blood is visible D. Wait until the examination is complete

B. Hand hygiene is indicated when moving from a contaminated to a clean body site.

A nurse begins an interview by saying, "Tell me what brought you in today." What type of communication technique is being used? A. Closed question B. Leading question C. Open-ended question D. Validation

C. Open-ended question. It allows the patient to tell the story in their own words.

A patient says, "I haven't been sleeping since my diagnosis. I keep thinking something terrible will happen." Which response is most therapeutic? A. "Everything will probably be fine." B. "Why are you thinking negatively?" C. "It sounds like this diagnosis has been causing you a lot of worry." D. "You need to try to get more sleep."

C. This response uses reflective listening and acknowledges the patient's feelings without false reassurance.

During the introduction phase, the patient's spouse answers every question for the patient. What should the nurse do? A. Continue because family members are reliable sources B. Ask the spouse to complete the interview C. Determine the patient's preference regarding the spouse's presence and confidentiality D. End the interview

C. During the introduction, the nurse should address visitors, privacy, confidentiality, and the patient's preferences.

The nurse has finished collecting the patient's history. Which action best represents the termination phase? A. Ask, "Tell me what brought you in." B. Review the plan, summarize important information, and ask whether the patient has additional questions C. Begin asking focused symptom questions D. Review the medical record before entering the room

B. Summarizing, reviewing the plan and follow-up, allowing final questions, and using teach-back occur during termination.

A patient with limited English proficiency arrives with an adult child who offers to interpret. Which action is most appropriate? A. Use the child because the patient trusts them B. Obtain a qualified interpreter and continue communicating directly with the patient C. Direct all questions to the interpreter D. Avoid asking sensitive questions

B. Use a qualified interpreter and interact directly with the patient rather than relying on family.

Which nurse statements are examples of communication traps? Select all that apply. A. "Everything is going to be okay." B. "Tell me more about the pain." C. "Why didn't you come to the hospital sooner?" D. "If I were you, I would have the surgery." E. "What concerns you most right now?"

A, C, D. False reassurance, "why" questions, and unwanted advice can interfere with therapeutic communication.

A patient says, "I've had terrible stomach pain since last night." Which question is best to ask FIRST to begin exploring the symptom? A. "Is it a 7 out of 10?" B. "Tell me more about the stomach pain." C. "You probably ate something bad, right?" D. "Do you need pain medication?"

B. Begin broadly and allow the patient to describe the symptom before narrowing to focused questions.

The nurse asks, "Does the pain become worse after eating or improve when you lie down?" Which part of OPQRSTU is being assessed? A. Quality B. Region C. Provocative/Palliative factors D. Timing

C. Provocative/Palliative factors assess what worsens or relieves the symptom.

A patient states, "I've had a burning sensation in my stomach for three days." Which portion of the information is objective? A. Burning sensation B. Three-day duration C. Patient's statement D. None of the information

D. All of the information came from the patient and is subjective.

Which finding is objective data? A. "My head hurts." B. "I feel dizzy." C. Temperature of 38.4°C D. "I've been nauseated since yesterday."

C. A measured temperature is objective data.

A patient arrives for the first visit with a new primary care provider and has no urgent complaint. Which type of history is most appropriate? A. Emergency B. Comprehensive C. Follow-up D. Focused

B. A comprehensive history is appropriate for a new patient and establishing baseline information.

A patient returns two weeks after beginning treatment for a specific problem. The nurse primarily needs to determine the patient's response to treatment. Which database is most appropriate? A. Complete B. Emergency C. Follow-up D. Comprehensive

C. A follow-up database evaluates an identified problem and the patient's response to treatment.

Which entry is most appropriate for the chief complaint? A. "Patient has pneumonia." B. "Possible gastrointestinal disorder." C. "My chest feels tight when I walk." D. "Patient appears to have anxiety."

C. The chief complaint should reflect the patient's reason for seeking care in the patient's own words and should not substitute a diagnosis.

A nurse asks about bathing, dressing, toileting, transferring, continence, and feeding. What is being assessed? A. Instrumental Activities of Daily Living B. Activities of Daily Living C. Review of Systems D. Mental status

B. Activities of Daily Living.

A patient can independently bathe, dress, and eat but can no longer shop, prepare meals, manage medications, or handle money. Which interpretation is most accurate? A. Activities of Daily Living are impaired B. Instrumental Activities of Daily Living are impaired C. No functional impairment exists D. The patient has impaired orientation

B. Shopping, meal preparation, medication management, and money management are Instrumental Activities of Daily Living.

The nurse constructs a diagram showing the patient's parents, siblings, grandparents, and health conditions occurring in the family. What is the nurse creating? A. Review of Systems B. Genogram C. Functional assessment D. SBAR

B. A genogram traces family relationships and possible genetic predispositions.

Which statement about a genogram is correct? A. It establishes a medical diagnosis B. It replaces the family history C. It helps identify family patterns and possible genetic predispositions D. It contains only the patient's immediate family

C. A genogram helps trace family relationships and potential genetic predispositions; it does not diagnose disease.

A patient reports feeling depressed. Which additional question is most important? A. "What is your favorite activity?" B. "Have you had thoughts of harming yourself or suicide?" C. "What foods have you eaten today?" D. "Do you have siblings?"

B. When depression is identified, the nurse should assess for suicidal thoughts.

A nurse documents, "Patient is obnoxious and refuses to cooperate." Which revision is BEST? A. "Patient has a bad attitude." B. "Patient is difficult." C. "Patient crossed arms, raised voice, and stated, 'I do not want to answer any more questions.'" D. "Patient is obviously angry."

C. Documentation should describe observable behaviors and use direct quotes rather than subjective judgments.

A student nurse administers a medication and plans to document it at the end of the shift. Which principle is most relevant? A. Documentation should occur as soon as possible after care B. Documentation should occur before care C. Only abnormal findings require documentation D. The student should wait until discharge

A. Findings and interventions should be documented as soon as possible.

Which nursing action is legally inappropriate? A. Documenting a patient's exact statement B. Documenting immediately after an intervention C. Charting an intervention before performing it D. Recording the patient's response

C. Never document care before it is performed.

The nurse receives a verbal order from a provider. Which action is appropriate? A. Write it down without repeating it B. Read the order back to the provider for confirmation C. Ask another nurse to interpret it later D. Wait until the provider enters it electronically

B. The nurse should read back the verbal order and confirm it.

Before obtaining a patient's blood pressure, the nurse learns that the patient drank coffee 10 minutes ago. What is the best action based on the course material? A. Measure immediately B. Wait until 30 minutes have passed since caffeine intake C. Have the patient stand D. Use a smaller cuff

B. Patients should avoid caffeine, exercise, and smoking for 30 minutes before blood pressure measurement.

A patient's blood pressure is unexpectedly high. The nurse notices that the cuff used was too small. What should the nurse suspect? A. The reading may be falsely high B. The reading may be falsely low C. Only the diastolic reading is affected D. Cuff size has no effect

A. A cuff that is too small can produce a falsely high blood pressure reading.

A student positions the patient's arm below heart level during blood pressure measurement. What effect should the nurse anticipate? A. Falsely low blood pressure B. Falsely high blood pressure C. No effect D. Falsely low pulse

B. Positioning the arm below heart level can produce a falsely high blood pressure reading.

A patient has a regular radial pulse. Which technique is appropriate according to the lecture? A. Count for 10 seconds B. Count for 15 seconds C. Count for 30 seconds and multiply by 2 D. Always count for 2 minutes

C. A regular adult radial pulse can be counted for 30 seconds and multiplied by 2.

The nurse detects an irregular radial pulse. Which action is most appropriate? A. Count for 15 seconds B. Assess the apical pulse C. Immediately document the radial rate as normal D. Ask the patient to hold their breath

B. An irregular radial pulse requires further assessment of the apical pulse.

The nurse assesses respirations without telling the patient that respirations are being counted. Why is this technique appropriate? A. Patients may voluntarily alter their breathing when aware it is being assessed B. Respirations are subjective data C. Respirations cannot be counted while awake D. It decreases body temperature

A. Respirations should be counted without making the patient aware because awareness can alter the breathing pattern.

A patient describes pain that began after tissue injury. Which category from the course material best fits this pain? A. Neuropathic B. Nociceptive/somatic C. Idiopathic D. Psychogenic

B. Nociceptive or somatic pain is associated with tissue damage.

A patient reports pain related to direct injury of a peripheral nerve. Which type of pain should the nurse recognize? A. Nociceptive B. Neuropathic C. Idiopathic D. Acute somatic

B. Neuropathic pain results from direct injury involving the peripheral or central nervous system.

The nurse calls a provider and states, "Mrs. Jones developed new confusion approximately 20 minutes ago." Which SBAR component is this statement primarily communicating? A. Situation B. Background C. Assessment D. Recommendation

A. Situation identifies the immediate reason for communication.

During the General Survey, which observations should the nurse include? Select all that apply. A. General appearance B. Posture C. Gait and mobility D. Behavior and affect E. Detailed family history

A, B, C, D. General appearance, body structure and posture, mobility and gait, and behavior are components of the General Survey.

A patient states, "I've felt weak all week." Which finding would support true weakness rather than fatigue? A. Reports feeling exhausted B. Wants to sleep during the day C. Demonstrates decreased muscle power D. Reports low energy

C. Weakness involves demonstrable loss of muscle power; fatigue is nonspecific weariness or loss of energy.

During the General Survey, the nurse notices the patient walks slowly and uses a cane. Which component is being assessed? A. Appearance B. Mobility C. Mood D. Health history

B. Gait and assistive-device use are components of mobility.

The nurse begins an integumentary examination. Which sequence is correct? A. Palpation then inspection B. Inspection then palpation C. Inspection, percussion, auscultation D. Auscultation then palpation

B. Skin assessment uses inspection followed by palpation.

Which findings should be assessed during an integumentary examination? Select all that apply. A. Color B. Temperature C. Moisture D. Turgor E. Lesions F. Bowel sounds

A, B, C, D, E. Skin assessment includes color, temperature, moisture, texture, edema, mobility, turgor, vascular findings, lesions, and hygiene.

The nurse pinches the patient's skin and observes how quickly it returns to its previous position. What is being assessed? A. Mobility B. Turgor C. Texture D. Edema

B. Turgor refers to the speed with which the skin returns.

The nurse assesses how easily the patient's skin can be lifted. What is being assessed? A. Mobility B. Turgor C. Moisture D. Thickness

A. Mobility refers to how easily the skin can be lifted.

The nurse identifies a skin lesion. Which characteristics should be included when documenting it? Select all that apply. A. Color B. Size C. Shape/pattern D. Location E. Exudate or odor F. Nurse's opinion about whether it looks dangerous

A, B, C, D, E. Lesions should be objectively described by characteristics such as color, size, elevation, number, texture, type, pattern/shape, grouping, surrounding skin, exudate/odor, and location.

The nurse observes a flat area of altered skin color. Which lesion is most consistent with this finding? A. Macule B. Papule C. Plaque D. Nodule

A. A macule is flat.

The nurse observes a small elevated lesion measuring less than 1 centimeter. Which lesion is most consistent with this finding? A. Macule B. Papule C. Plaque D. Scar

B. A papule is an elevated lesion less than 1 centimeter.

A patient has an elevated lesion larger than 1 centimeter. Which lesion is most consistent with this finding? A. Macule B. Papule C. Plaque D. Excoriation

C. A plaque is an elevated lesion greater than 1 centimeter.

Which findings are SECONDARY skin lesions? Select all that apply. A. Scar B. Fissure C. Excoriation D. Papule E. Vesicle F. Ulcer

A, B, C, F. Scars, fissures, excoriations, and ulcers are secondary lesions. Papules and vesicles are primary lesions.

The nurse presses on a patient's petechiae. What should the nurse expect? A. Complete blanching B. No blanching C. Immediate disappearance D. Increased capillary refill

B. Petechiae do not blanch.

Which skin finding would be expected to blanch? A. Ecchymosis B. Petechiae C. Angioma D. Hematoma

C. Angiomas blanch; petechiae, ecchymoses, and hematomas do not.

A nurse assesses a mole using the ABCDE approach. Which finding is most concerning within that framework? A. Symmetrical appearance B. Regular border C. Variation in color D. No change over time

C. Color variation is one of the concerning ABCDE characteristics.

Which patient statement indicates a need for additional skin-cancer prevention teaching? A. "I'll try to avoid excessive sun exposure." B. "Artificial tanning is safer than outdoor tanning." C. "I'll use sunscreen." D. "I'll pay attention to changes in my skin."

B. The course identifies avoiding artificial tanning as part of skin-cancer risk reduction.

The nurse notices decreased hair growth on both lower legs. Which finding from the course should the nurse consider? A. Peripheral arterial disease B. Normal sweat-gland function C. Increased venous circulation D. Normal nail development

A. Loss of leg hair may occur with peripheral arterial disease.

Which nail finding should the nurse recognize as expected? A. Clubbing B. Capillary refill of 5 seconds C. Smooth, firm, pink nails with brisk capillary refill D. Markedly irregular contour

C. Normal nails are pink, smooth, firm, rounded, without clubbing, and have brisk capillary refill under 3 seconds.

A patient with limited mobility remains in the same position for prolonged periods. Which process increases the risk for pressure injury? A. Increased blood flow B. Compression that decreases blood flow C. Increased skin mobility D. Increased sebaceous secretion

B. Prolonged compression can reduce or obliterate blood flow and contribute to pressure injury.

The nurse is assessing level of consciousness. The patient is awake, has eyes open, looks at the nurse when spoken to normally, and responds fully. How should this be documented? A. Lethargic B. Alert C. Obtunded D. Stuporous

B. Alert.

A patient appears drowsy, looks at the nurse and answers when questioned, but then falls back asleep. What level of consciousness is present? A. Alert B. Lethargic C. Obtunded D. Comatose

B. Lethargic.

A patient opens the eyes and looks at the nurse but responds slowly and appears somewhat confused. What level of consciousness is present? A. Lethargic B. Obtunded C. Stuporous D. Comatose

B. Obtunded.

A patient arouses only after painful stimulation and returns to an unresponsive state when the stimulation stops. What level of consciousness is present? A. Alert B. Lethargic C. Stupor D. Coma

C. Stupor.

Which patient finding is consistent with coma? A. Drowsy but responds to questions B. Responds slowly and appears confused C. Arouses only with painful stimuli D. Does not open eyes or respond to voice or painful stimuli

D. Coma.

A patient states, "I've felt extremely sad for the past month." During the interview, the nurse observes a flat facial expression and little change in tone of voice. Which interpretation is correct? A. The patient's statement describes affect and observations describe mood B. The statement describes mood and observations describe affect C. Both describe mood D. Both describe affect

B. Mood is the sustained internal emotional state. Affect is the observable expression of emotion.

A patient speaks clearly but cannot understand what the nurse is saying. Which language disturbance is most consistent with the course material? A. Broca's aphasia B. Wernicke's aphasia C. Dysarthria D. Dysphonia

B. Wernicke's aphasia is receptive.

A patient understands the nurse's questions but has difficulty expressing words. Which condition is most consistent with this finding? A. Wernicke's aphasia B. Broca's aphasia C. Dysarthria D. Delirium

B. Broca's aphasia is expressive.

A patient repeatedly fabricates events to fill gaps in impaired memory. Which thought-process term describes this behavior? A. Echolalia B. Confabulation C. Perseveration D. Clanging

B. Confabulation is fabrication of facts or events to fill gaps caused by impaired memory.

During conversation, the patient repeatedly returns to the same word or idea despite attempts to move to another subject. Which term best describes this? A. Perseveration B. Echolalia C. Flight of ideas D. Circumstantiality

A. Perseveration is persistent repetition of words or ideas.

A patient continuously shifts rapidly from one topic to another during accelerated speech. Which thought-process abnormality is most consistent? A. Blocking B. Flight of ideas C. Confabulation D. Perseveration

B. Flight of ideas is an almost continuous flow of accelerated speech with abrupt changes from one topic to another.

A patient states that rustling leaves outside are people whispering about them. Which finding is present? A. Hallucination B. Illusion C. Confabulation D. Neologism

B. An illusion is a misinterpretation of a real external stimulus. The rustling leaves are actually present but are misinterpreted.

A patient hears a voice when no external sound is present. Which finding is present? A. Illusion B. Hallucination C. Perseveration D. Circumstantiality

B. A hallucination is a perception-like experience without actual external stimulation.

The nurse asks a patient to state their name, current location, today's date, and why they are in the hospital. What is being assessed? A. Judgment B. Orientation C. Remote memory D. Abstract thinking

B. Orientation to person, place, time, and situation.

The nurse asks a patient to spell a word backward and perform serial 7s. Which cognitive function is primarily being assessed? A. Attention and concentration B. Remote memory C. New learning D. Judgment

A. Attention and concentration can be assessed with digit span, serial 7s, and spelling backward.

The nurse gives a patient four words to repeat and asks for the words again 5 minutes later. What is being assessed? A. Remote memory B. New learning ability C. Judgment D. Orientation

B. New learning ability.

The nurse asks a patient about previous jobs and schools attended. Which cognitive function is being assessed? A. Recent memory B. Remote memory C. New learning D. Orientation

B. Remote memory.

An older hospitalized patient develops confusion suddenly. The patient's attention and awareness fluctuate throughout the day. Which condition best matches this pattern? A. Dementia B. Delirium C. Normal aging D. Chronic memory impairment

B. Delirium develops rapidly and fluctuates.

The family reports that a patient's memory and ability to function socially have gradually worsened over several years. Which disorder best matches the pattern? A. Delirium B. Dementia C. Stupor D. Acute confusion

B. Dementia involves memory and cognitive impairment with a generally gradual or slow onset.

Which tool would the nurse use to screen an adult for cognitive dysfunction or dementia? A. AUDIT B. DAST C. Mini-Mental State Examination D. OPQRSTU

C. Mini-Mental State Examination.

Which functions are assessed by the Mini-Mental State Examination? Select all that apply. A. Orientation B. Registration C. Attention D. Calculation E. Recall F. Language

A, B, C, D, E, F. The Mini-Mental State Examination evaluates orientation, registration, attention, calculation, recall, language, and ability to follow simple instructions.

The nurse suspects depression during the mental status assessment. Which action is most important according to the course material? A. Avoid discussing suicide because it may upset the patient B. Directly assess for suicidal ideation or plans C. Ask the family instead D. Wait until a provider assesses the patient

B. Patients at risk should be directly assessed for suicidal ideation or plans.

The nurse needs to assess substance use. Which opening is most appropriate? A. "You don't use drugs, do you?" B. "Why do you drink so much?" C. "I ask all patients about alcohol, tobacco, and other substance use." D. "Your family thinks you have a drug problem. Is that true?"

C. Substance-use assessment should be routine and nonjudgmental rather than leading or accusatory.

A patient needs screening specifically for alcohol-related substance use concerns. Which tool should the nurse recognize? A. DAST B. AUDIT C. Mini-Mental State Examination D. ABCDE

B. Alcohol Use Disorders Identification Test (AUDIT).

A patient needs screening specifically for drug-related substance use concerns. Which tool should the nurse recognize? A. AUDIT B. DAST C. Mini-Mental State Examination D. FIFE

B. Drug Abuse Screening Test (DAST).