Nursing Assessment
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Nursing is just not about taking care of the patients in recovery beds by feeding them and administering medication, there is much more to it. This nursing assessment will help you as a nurse to better understand different nursing concepts.
- 1.Critical thinking
- A.
Is a step by step linear process
- B.
Is a multidimensional thinking process
- C.
Is not required when making sound diagnostic reasoning and clinical judgement
- D.
Does not grow
- 2.Collecting a small database concerning one problem, cue complex, or body system is which type of data collecting?
- A.
Complete Database
- B.
Episodic Database
- C.
Follow-Up Database
- D.
Emergency Database
- 3.Health Inequity
- A.
Is the inequalities in heath that are unnecessary and avoidable and differences that are considered unfair and unjust.
- B.
Is a generic term used to designate differences, variations, and disparities in the health status of individual and groups.
- C.
Health inequality and health inequity are the same
- D.
Example include the higher incidence of deaths in the prime of life for women in Canada compared with men, largely due to breast and other cancers
- 4.Which of these are considered open ended questions?
- A.
Have you ever had pain in the eye?
- B.
From a scale of 1 to 10, 1 being the weakest and 10 being the strongest, how much would you rate your pain?
- C.
Is it okay if I touch you?
- D.
How have you been getting along?
- 5.Ms. B is at the clinic today and the nurse is explaining what a heart attack is. The nurse says "A myocardial infarction can be serious and is caused by a blood clot that blocks one of the coronary arteries. This can lead to a rupture of a vulnerable atherosclerotic plaque. This is an example of which type of interviewing traps
- A.
Providing false assurance or reassurance
- B.
Giving unwanted advice
- C.
Using professional Jargon
- D.
Interrupting
- 6.When interviewing Mr.C, a 89 year old man from Greece who doesn't understand English, it is important to
- A.
Make sure you speak louder
- B.
Make sure to exaggerate your lip movement for better understanding
- C.
Find an interpreter or speak slowly
- D.
Make sure you do not use hand gestures because this can invade their personal space
- 7.
- A.
Provocative or palliative, quality or quantity, region or radiation, severity scale, timing, and understanding patient's perception
- B.
Past health, quality of health, requirement of health, standard of health, Teaching of health, and understanding of health
- C.
Palpating, questioning, reasoning, signaling, teaching, and understanding
- D.
None of the above
- 8.Knowing clients family history
- A.
May be of genetic significance for the data collection
- B.
May tell a clients prolonged contact with any communicable disease
- C.
May indicate effect of a family members illness on the client
- D.
All of the above
- 9.Bathing, dressing, toileting, eating are examples of
- A.
Instrumental activities of daily living
- B.
Activities that patient needs full assistance in performing
- C.
Activities of daily living
- D.
Activities that patient needs no assistance in performing
- 10.Client verbally reports pain at a level of 8 or 9 when it becomes sharp is an example of
- A.
Subjective data
- B.
Objective data
- C.
Data clustering
- D.
Data analysis and interpreting
- 11.When documenting
- A.
Other health care provider may document for you
- B.
Do not generalize or form judgements through written communication
- C.
Do not be descriptive. Time is wasted on documentation for writing everything seen, heard, felt or smelled.
- D.
It is okay not to record assessment during your next shift
- 12.Failure to consider conflicting cues, using an insufficient number of cues, using unreliable or invalid cues are which source of diagnostic error?
- A.
Collecting
- B.
Interpreting
- C.
Clustering
- D.
Labelling
- 13.Resonant is a type of sound that can be heard while percussing. What are some of its characteristics.
- A.
A dead stop of sound, absolute dullness, very short duration and can be heard over bones
- B.
A muffled thud, short in duration, and can be heard over the liver
- C.
Clear and hollow sound, moderate in duration and can be heard over normal lung tissue
- D.
Musical and drumlike, sustained longest duration, and can be heard over stomach
- 14.
- A.
Using a large cuff for thin clients
- B.
Taking blood pressure when the client wakes up
- C.
Asking client to support own arm
- D.
If failing to record measurement, take it again right away
- 15.When feeling for client pulse, take into account the
- A.
Age, gender, ethnocultural background and weight
- B.
Amount of stress, weight, exercise and emotions
- C.
Physical appearance, body structure, behaviour and mobility
- D.
Rate, rhythm, force and elasticity
- 16.Maximum pressure felt on the artery during left ventricular contraction is the
- A.
Systolic pressure
- B.
Diastolic pressure
- C.
Pulse pressure
- D.
Mean arterial pressure
- 17.Mr. D, a client that is on bed rest, reports having pain on the bony prominences of his spine. Further inspection shows that a lesion has formulated on Mr. D's spine. This pain is considered_________ and if unresolved for a longer period a time such as 6 months, the pain can be classified as__________
- A.
Nociceptive pain, acute pain
- B.
Nociceptive pain, persistent pain
- C.
Neuropathic pain, acute pain
- D.
Neuropathic, persistent pain
- 18.Which of these statements are true about pain?
- A.
Pain should be considered a normal part of aging
- B.
Older adults will often deny having pain for fear of dependency
- C.
Pain in neonates and infants cannot be assessed
- D.
Psychological changes that take place that may indicate the presence of pain includes sweating, increase blood pressure and heart rate, vomiting and nausea
- 19.The pain assesment tool that ask the patient to choose a number that rates the level of pain, with 0 being no pain and the highest anchor 10 indicating the worst pain is
- A.
The short-form McGill pain questionnaire
- B.
The brief pain inventory
- C.
Numeric rating scale
- D.
Descriptor scale
- 20.What is the order of the Nociception phase
- A.
Perception, transmission, transduction, modulation
- B.
Transmission, perception, modulation, transduction
- C.
Transduction, transmission, perception, modulation
- D.
Transduction, modulation, perception, transmission
- 21.Which of these demonstrate the highest risk for suicide
- A.
Ms. E who had prior suicide attempt and is now in a rehabilitation centre
- B.
Mr. F jokingly tells his friend that he was wants to shoot himself with his fathers pistol because there is so much to deal with in life. The next day Mr. F had ran away from home and left his family a letter saying he is giving up
- C.
Mr. G who is recovering from a traumatic brain injury from a car crash that has killed his wife
- D.
Holly, an 8 year old girl is giving away all her toys to the orphanage
- 22.The awareness of the objective world in relation to the self is
- A.
Perception
- B.
Orientation
- C.
Attention
- D.
Consciousness
- 23.Some behaviour to look at when assessing the mental health status of the patient is looking at
- A.
Level of Consciousness, speech, mood and affect, and facial expression
- B.
Grooming hygiene, dress, body movement, and posture
- C.
Attention span, recent memory, and remote memory
- D.
Orientation, posture, facial expression, attention span
- 24.Which of the following is not part of the MiniMental State Examination?
- A.
Time orientation
- B.
Place orientation
- C.
Registration of five words
- D.
Reading
- 25.Which layer of the skin contains adipose tissue, provide insulation for temperature control and aids in protection by its soft cushioning effect
- A.
Both the dermis and subcutaneous layer
- B.
Dermis layer
- C.
Epidermis layer
- D.
Subcutaneous layer
- 26.When a nurse is inspecting a patients skin, he notices a pigmentation under the client's feet. Which of the following is an abnormal finding of the mole?
- A.
Diameter of the mole is 4-5mm big
- B.
Elevation of the pigmentation
- C.
Borders are smooth
- D.
Pigmentation is in a shape of an oval where two halves look the same
- 27.Moving the sole of the foot outward at the ankle is
- A.
Flexion
- B.
Extension
- C.
Eversion
- D.
Inversion
- 28.A bruit
- A.
Diminishes pulse feeling
- B.
Is a unilateral distension of the external jugular veins
- C.
Indicates turbulence due to a local vascular cause
- D.
Is the condition in which pressure over the carotid sinus leads to a decreased heart rate
- 29.The internal juglar pulse
- A.
Is palpable, higher and medial to the sternomastoid muscle and unaffected by the position of the person
- B.
Is not palpable, pulse drops as person sits, and is lower and more lateral under/behind the sternomastoid muscle
- C.
Is palpable, does not vary with respiration and the quality of the pulse is brisk and localized
- D.
Is not palpable, is unaffected by position of person and does not vary with respiration
- 30.The apical pulse can be found
- A.
On the radial side of the wrist
- B.
At the base of the neck
- C.
On the lateral edge of the ankle
- D.
On either the forth or fifth intercostal space
- 31.Cyanosis or pallor is
- A.
The swelling of the feet and legs
- B.
Changing colour of the facial skin
- C.
Needing to pee during the middle of the night
- D.
All of the above
- 32.Which of these statement is true regarding the lungs
- A.
Both lungs are divide into upper, middle, and lower lobes
- B.
Each lobes are separated by fissures
- C.
The posterior lung is mostly upper lobe
- D.
The right lung is narrower than the left lung because the heart bulges to the right
- 33.When percussing the lung field, what sound can be heard over the lungs of a child?
- A.
Resonant
- B.
Hyperresonant
- C.
Flat
- D.
Dull
- 34.A nurse is listening to a clients breathing sound and notes that she heard broncial sounds in the trachea, bronchovesicular sounds over the major bronchi and vesicular sounds over the peripheral lung fields.
- A.
Normal breathing sounds of the bronchial should be heard over the bronchi and not the trachea
- B.
Normal breathing sound of the lung field should be bronchovesicular
- C.
No sounds she be heard over the bronchi
- D.
The nurse heard normal breathing sounds
- 35.Which part of lung assessment is it when the nurse assess normal breath sounds, note any abnormal breath sounds, and note any adventitious sounds?
- A.
Inspection
- B.
Palpation
- C.
Percussion
- D.
Auscultation
- 36.A lateral S-shaped curvature of the thoracic and lumbar spine indicates
- A.
A Barrel chest
- B.
Scoliosis
- C.
A Normal chest
- D.
Kyphosis
- 37.How are veins different from arteries?
- A.
Veins are a low pressure system
- B.
Veins contain muscle fibers
- C.
A and B
- D.
None of the above
- 38.Which of these sutures separate the head lengthwise between the two parietal bones
- A.
Coronal
- B.
Sagittal
- C.
Lambdoid
- D.
None of the above
- 39.When palpating the lymph nodes of the face, the nurse should
- A.
Use a gentle circular motion of the finger pads
- B.
Use gentle pressure as nodes can get pushed into the muscle
- C.
Better to use both hands to compare two sides symmetrically
- D.
Do all of the above
- 40.The nurse notices that the thyroid gland of a patient is enlarged. The nurse should
- A.
Not proceed any further as pressure could rupture the gland
- B.
Listen for presence of bruit which indicates hyperplasia
- C.
Notify the physician for further instructions
- D.
Administer medication to reduce the size of the thyroid gland
- 41.All the lymph nodes drain downward except for the
- A.
Supraclavicular node
- B.
Deep cervical node
- C.
Superficial cervical node
- D.
Occipital node
- 42.Fontanelles
- A.
Are found in pregnant women when their thyroid gland enlarges due to hyperplasia
- B.
Are soft spots found in infants skull that allows for the growth of the brain and eventually ossify
- C.
Are the name of the facial sags caused from decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin of aging adult
- D.
None of the above
- 43.Kiesselbach's plexus is a rich vascular network that is the most common site :
- A.
Of redder nasal mucosa
- B.
Of oral mucosa
- C.
Of nose bleed
- D.
For bacteria and dust to be filtered out
- 44.Which of these sinus(es) are absent at birth
- A.
Maxillary
- B.
Ethmoid
- C.
Sphenoid and frontal
- D.
Maxillary and frontal
- 45.A nurse assess a clients oral cavity notes that the larger vallate papillae are in an inverted v shape. Which of these statement is true about the nurses assessment?
- A.
This is an abnormal growth and can cause the client to lose sense of taste
- B.
These are symptoms of lesions in the mouth
- C.
The inverted V shape helps client with pushing down ingested food
- D.
Inverted V shape is not abnormal growth
- 46.When inspecting the tonsil, tonsils are graded as 1+ , 2+, 3+, and 4+. Which of these are normally seen in healthy people?
- A.
1+
- B.
2+
- C.
3+
- D.
4+
- 47.The deep tendon reflex consist of what components?
- A.
An intact sensory nerve and a functional synapse in the cord
- B.
An intact sensory nerve, a functional synapse in the cord and an intact motor nerve fibre
- C.
An intact sensory nerve, a functional synapse in the cord, an intact motor nerve fibre, and the neuromuscular junction
- D.
An intact sensory nerve, a functional synapse in the cord, an intact motor nerve fibre, the neuromuscular junction and a competent muscle
- 48.Cranial nerve 8 is
- A.
The acoustic nerve and its functions are hearing and equilibrium
- B.
The hypoglossal nerve and its function is the movement of the tongue
- C.
The spinal accessory nerve and its function is movement of trapezius and sternomastoid muscles
- D.
The olfactory nerve and its function is smell
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