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NUR631-ADVANCED HEALTH ASSESSMENT TEST 1 LATEST 2024/
QUESTIONS WITH 100% CORRECT ANSWERS GRADED A+
“What is the function of the goblet cells of the lungs? A. To enable the exchange of gases B. To sweep away particulate matter C. To provide space for gas exchange
D. To entrap small particulate matter - CORRECT ANSWER D"
"What assessment finding will the nurse document in a patient with pneumonia? A. A smooth chest expansion B. A lag in the chest expansion C. A palpable grating sensation
D. A slight inspiratory variation - CORRECT ANSWER B"
"Increased tactile fremitus would be evident in an individual who has which of the following conditions? A. Emphysema B. Pneumonia C. Crepitus
D. Pneumothorax - CORRECT ANSWER B"
"A common clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD) is :A. periodic breathing patterns .B. pursed-lip breathing. C. unequal chest expansion
.D. hyperventilation. - CORRECT ANSWER B"
"Which of the following is not included in the definition of the thoracic cage? A. Sternum B. Ribs C. Costochondral junction
D. Diaphragm - CORRECT ANSWER C"
"Inspiration is primarily facilitated by which of the following muscles? A. Diaphragm and rectus abdominis B. Trapezius and sternomastoids C. Internal intercostal and abdominis
D. Diaphragm and intercostal - CORRECT ANSWER D"
"Which of the following voice sounds would be a normal finding?
A. The voice transmission is distinct and sounds close to the ear. B. The "eeeee" sound is clear and sounds like "eeeee." C. The whispered sound is transmitted clearly.
D. Whispered "1-2-3" is audible and distinct. - CORRECT ANSWER B"
"The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of elderly adults cause: A. hyperventilation. B. spontaneous atelectasis. C. decreased surface area for gas exchange.
D. decreased dead space. - CORRECT ANSWER C"
"You note a lesion during a skin assessment. Which is the best way to document this finding? A. Raised, irregular lesion the size of a quarter, located on dorsum of left hand B. Open lesion with no drainage or odor, approximately 1/4 inch in diameter C. Pedunculated lesion below left scapula with consistent red color and no drainage or odor D. Dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, with no
drainage - CORRECT ANSWER D"
"You examine the nail beds of a patient. Which finding indicates a normal angle? A. 60 degrees B. 100 degrees C. 160 degrees
D. 180 degrees - CORRECT ANSWER C"
"You are assessing capillary refill. The room is warm. Which finding would be considered normal? A. <1 second B. >2 seconds C. 2 to 3 seconds
D. Time is not significant as long as color returns - CORRECT ANSWER A"
"During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. What is your best response after assessing the areas? A. "These re the result of sun exposure and do not require treatment." B. "These are related to exposure to the sun, they may become cancerous." C. "These are the skin tags that occur with agin, No treatment is required.
"D. "I'm glad you brought this to my attention. I will arrange for a biopsy." - CORRECT
ANSWER A"
"An area of thin shiny skin with decreased visibility of normal skin markings is most likely:
d.46-year-old woman whose waist measures 30 inches and hips measure 38 inches - CORRECT
ANSWER A"
"A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? a.The risks of undernutrition should be included. b.Offer methods to reduce the stress in her life. c.Provide information regarding a diet low in saturated fat.
d.This condition is hereditary; she can do nothing to change the levels - CORRECT ANSWER
C"
"In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? a.Increase in hair growth b.Inadequate nutrient food intake c.Weight 10% to 20% over ideal
d.Sore, inflamed buccal cavity - CORRECT ANSWER B"
"A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find? a.Poor skin turgor b.Decreased serum albumin c.Increased lymphocyte count
d.Triceps skinfold less than standard - CORRECT ANSWER B"
"The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: a.Slowed gastrointestinal motility. b.Hyperstimulation of the salivary glands. c.Increased sensitivity to spicy and aromatic foods.
d.Decreased gastrointestinal absorption causing esophageal reflux. - CORRECT ANSWER A"
"Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? a.Decreasing the amount of carbohydrates to prevent lean muscle catabolism b.Increasing the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis c.Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass
d.Increasing the number of calories she is eating because of the increased energy needs of the
older adult - CORRECT ANSWER C"
"The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a.Ask the patient to take deep breaths to relax the abdominal musculature .b.Consider this finding as normal, and proceed with the abdominal assessment .c.Increase the amount of strength used when attempting to percuss over the abdomen.
d.Decrease the amount of strength used when attempting to percuss over the abdomen. -
CORRECT ANSWER C"
"The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year- old child. The nurse should :a.Palpate over the area for increased pain and tenderness. b.Ask the child to take shallow breaths, and percuss over the area again. c.Immediately refer the child because of an increased amount of air in the lungs.
d.Consider this finding as normal for a child this age, and proceed with the examination -
CORRECT ANSWER D"
"A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a.Count the patients respirations. b.Bilaterally percuss the thorax, noting any differences in percussion tones. c.Call for a chest x-ray study, and wait for the results before beginning an assessment
.d.Inspect the thorax for any new masses and bleeding associated with respirations. - CORRECT
ANSWER B"
"The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a.Slope of the earpieces should point posteriorly (toward the occiput) .b.Although the stethoscope does not magnify sound, it does block out extraneous room noise .c.Fit and quality of the stethoscope are not as important as its ability to magnify sound.
d.Ideal tubing length should be 22 inches to dampen the distortion of sound. - CORRECT
ANSWER B"
"The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a.Is used to listen for high-pitched sounds. b.Is used to listen for low-pitched sounds. c.Should be lightly held against the persons skin to block out low-pitched sounds
"A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a.Ask the parent to place the child on the examining table. b.Have the parent remove all of the childs clothing before the examination. c.Allow the child to keep a security object such as a toy or blanket during the examination. d.Initially focus the interactions on the child, essentially ignoring the parent until the childs trust
has been obtained - CORRECT ANSWER C"
"The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurses technique is most accurate? a.Asking questions enhances the childs autonomy b.Asking the child for permission helps develop a sense of trust c.This question is an appropriate statement because children at this age like to have choices d.Children at this age like to say, No. The examiner should not offer a choice when no choice is
available - CORRECT ANSWER D"
"With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on the penlight? a.Infant b.Preschool child c.School-age child
d.Adolescent - CORRECT ANSWER B"
"The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a.Explain the procedures in detail to alleviate the childs anxiety b.Give the child feedback and reassurance during the examination. c.Do not ask the child to remove his or her clothes because children at this age are usually very private .d.Perform an examination of the ear, nose, and throat first, and then examine the thorax and
abdome - CORRECT ANSWER B"
"When examining a 16-year-old male teenager, the nurse should: a.Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b.Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c.Talk to him the same manner as one would talk to a younger child because a teens level of understanding may not match his or her speech. d.Provide feedback that his body is developing normally, and discuss the wide variation among
teenagers on the rate of growth and development. - CORRECT ANSWER D"
"During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a."How do you feel today?" b."Would you please repeat the following words? "c."Have these medications had any effect on your pain?"
d."Has this pain affected your ability to get dressed by yourself?" - CORRECT ANSWER A"
"The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a.Administer the FACT test. b.Ask him to describe his first job. c.Give him the Four Unrelated Words Test.
d.Ask him to describe what television show he was watching before coming to the clinic. -
CORRECT ANSWER C"
"A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. a.Invent; within 5 minutes b.Invent; within 30 seconds c.Recall; after a 30-minute delay
d.Recall; after a 60-minute delay - CORRECT ANSWER C"
"During a mental status assessment, which question by the nurse would best assess a person's judgment? a."Do you feel that you are being watched, followed, or controlled? "b."Tell me what you plan to do once you are discharged from the hospital." c."What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?
"d."What would you do if you found a stamped, addressed envelope lying on the sidewalk?" -
CORRECT ANSWER B"
"Which of these individuals would the nurse consider at highest risk for a suicide attempt? a.Man who jokes about death b.Woman who, during a past episode of major depression, attempted suicide c.Adolescent who just broke up with her boyfriend and states that she would like to kill herself d.Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and
plans to use a gun - CORRECT ANSWER D"
c.This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d.The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed
to evaluate cognition changes over time. - CORRECT ANSWER C"
"The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a.Global b.Broca's c.Dysphonic
d.Wernicke's - CORRECT ANSWER A"
"A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: a.Blocking b.Clanging c.Echolalia
d.Neologism - CORRECT ANSWER B"
"During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a.Social phobia b.Compulsive disorder c.Generalized anxiety disorder
d.Posttraumatic stress disorder - CORRECT ANSWER B"
"The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a.Cognitive impairment b.Amnesia c.Delirium
d.Attention-deficit disorder - CORRECT ANSWER A"
"In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. "This has been a difficult year for you." b. "I don't know how anyone could handle that much stress in 1 year!" c. "What did you do to cope with the loss of both your husband and mother?"
d. "That is a lot of stress; now let's go on to the next section of your history." - CORRECT
ANSWER C"
"In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patient's reliability .b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use.
d. This information is not necessary unless a drinking problem is obvious - CORRECT
ANSWER B"
"The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. "Maybe she is just teething." b. "I will check her ear for an ear infection." c. "Are you sure she is really having pain?"
d. "Describe what she is doing to indicate she is having pain." - CORRECT ANSWER D"
"During an assessment of a patient's family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a person's near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patient's family members up to five generations back
d. Description of the health of a person's children and grandchildren - CORRECT ANSWER B"
"A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child's birth weight b. Age at which he crawled c. Whether the child has had the measles
d. Child's reactions to previous hospitalizations - CORRECT ANSWER D"
"As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years.
d. A recommendation cannot be made until the physician is consulted. - CORRECT ANSWER
B"
"d. "How many times a day do you have a bowel movement? - CORRECT ANSWER B"
"The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones .c. The functional assessment can identify any problems with memory the individual may be experiencing
.d. It helps determine how a person is managing day-to-day activities. - CORRECT ANSWER
D"
"The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L
d. Body temperature of 100° F - CORRECT ANSWER A"
"A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. "It is a sharp, burning pain in my stomach." b. "I also have the sweats and nausea when I feel this pain." c. "I think this pain is telling me that something bad is wrong with me."
d. "This pain happens every time I sit down to use the computer." - CORRECT ANSWER D"
"During an assessment, the nurse uses the CAGE test. The patient answers "yes" to two of the questions. What could this be indicating?a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse
assessment. - CORRECT ANSWER D"
"The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. "Do you believe in God?" b. "Are you a part of any religious or spiritual congregation?" c. "Do you consider yourself to be a religious or spiritual person?"
d. "How does your religious faith influence the way you think about your health?" - CORRECT
ANSWER B"
"The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. "Please stay during the interview; you can answer for her if she does not know the answer." b. "It would help to interview the three of you together." c. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?" d. "While I interview your daughter, will you step out to the waiting room and complete these
family health history questionnaires?" - CORRECT ANSWER D"
"The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. "Why did you come to the United States?" b. "When did you come to the United States and from what country?" c. "What made you leave your native country?"
d. "Are you planning to return to your home?" - CORRECT ANSWER B"
"The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. "Where is the headache pain?" b. "Did you have these headaches as a child?" c. "On a scale of 1 to 10, how bad is the pain?" d. "How often do the headaches occur?" e. "What makes the headaches feel better?"
f. "Do you have any family history of headaches? - CORRECT ANSWER A C D E"
"In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d.
Confrontation. - CORRECT ANSWER D"
"When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a.
Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in
your pocket. - CORRECT ANSWER D"
"The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a.Apologize, because using interpretation can be demeaning for the patient. b.Allow time for the patient to confirm or correct the inference. c.Continue with the interview as though nothing has happened.
d.Immediately restate the nurses conclusion on the basis of the patients nonverbal response. -
CORRECT ANSWER B"
"During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d.
It sounds as though you have made your decision. I think it is a good one. - CORRECT
ANSWER C"
"A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman.
d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor
cannot be tolerated without medication. - CORRECT ANSWER B"
"During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation
program we offer? - CORRECT ANSWER B"
"As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d.
I can see that you are very upset. Perhaps we should discuss this later. - CORRECT ANSWER
A"
"A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d.
Using blunt language to deal with distasteful topics. - CORRECT ANSWER C"
Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d.
Tell the child that by using the blood pressure cuff, we can see how strong her muscles are. -
CORRECT ANSWER D"
"A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d.
Use slang language when possible to help him open up. - CORRECT ANSWER B"
"A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of
what is said - CORRECT ANSWER A"
"The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d.
Speak loudly and with exaggerated facial movement when talking with him because doing so will
help him lip read. - CORRECT ANSWER A"
"During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d.
I can see that you feel sad about this; why dont we talk about something else? - CORRECT
ANSWER B"
"A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask
him to move away. - CORRECT ANSWER A"
"A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a.The woman is nervous and embarrassed. b.She has something to hide and is ashamed .c.The woman is showing inconsistent verbal and nonverbal behaviors.
d.She is showing that she is carefully listening to what the nurse is saying. - CORRECT
ANSWER D"
