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Excelsior College NUR 104 MODULE 1-8 QUIZES With Correct Answers and Rationales
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Excelsior College NUR 104 MODULE 1-8 QUIZES With Correct Answers and Rationales
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Module 1:Knowledge check quiz
Question 1
The nursing instructor asks students how they would assess the fifth vital sign. Which student would
be correct?
“I would have the client rate her pain on a scale of 0 to 10.” (Pain is considered to be the “fifth
vital sign.”)
“I would ask the client when she had her last bowel movement.”
“I would take the client’s pulse oximetry reading.”
“I would interview the client about history of tobacco use.”
Chapter number and title: 19, Vital Signs
Chapter learning objective: Discuss expected normal vital signs findings for various age-
groups. Chapter page reference: p. 421
Question 2
An adult client’s axillary temperature is 100.8°F. The nurse realizes this is outside normal range for
this client and that axillary temperatures do not reflect core temperature. What should the nurse do to
obtain a good estimate of the core temperature?
Add 1°F to 100.8°F to obtain an oral equivalent.
Add 2°F to 100.8°F to obtain a rectal equivalent.
Obtain a rectal temperature reading. (Rectal temperatures are most reliable and most accurately reflect
the core temperature.)
Obtain a tympanic membrane reading.
Chapter number and title: 19, Vital Signs
Chapter learning objective: Describe the physiological processes involved in regulating body
temperature, pulse, respirations, and blood pressure. Chapter page reference: p. 422
Question 3
In evaluating a client’s blood pressure for hypertension, what is the most important action for the
nurse to take
Use the same type of manometer each time.
Auscultate all five Korotkoff sounds.
Measure the blood pressure in both arms.
Monitor the blood pressure for a pattern. (Blood pressure fluctuates a great deal during the day and is
influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after
two or more BP readings taken on separate occasions.)
Chapter number and title: 19, Vital Signs
Chapter learning objective: Describe the physiological processes involved in regulating body
temperature, pulse, respirations, and blood pressure. Chapter page reference: p. 444
Question 4
The nurse provides client education regarding hypertension prevention and management. Which
statement indicates that the client understands the instructions?
“I don’t have to worry if my blood pressure is high once in a while.”
“I guess I will have to make sure I don’t drink too much water.”
“I can lose some weight to help lower my blood pressure.” ( A single lifestyle change, such as
weight loss, can lower blood pressure (BP).)
“I will need to reduce the amount of milk and other dairy products I consume.”
Chapter number and title: 19, Vital Signs
Question 5 ( partial) 0. pts
,Why does the nurse working in an ambulatory care program ask questions about the client’s locus of
control? Select all that apply.
People who feel in charge of their own health are the easiest to motivate toward change.
(Clients who feel in charge of their own health are the easiest to motivate toward positive change.)
People who feel powerless about preventing illness are least likely to engage in health
promotion activities. (People who feel powerless about preventing illness are least likely to engage in
health promotion activities.)
People who respond to direction from respected authorities often prefer a health promotion
program supervised by a health provider. (People who respond to direction from respected authorities
often prefer a health promotion program that is supervised by a health provider.)
? People who feel in charge of their own health are less motivated by health promotion activities.
(Clients who feel in charge of their own health are the easiest to motivate toward positive change.)
People who feel in charge of their own health demonstrate control, commitment, and challenge.
Chapter number and title: 27, Health Promotion
Chapter learning objective: Identify the areas of assessment in relation to developing a health
promotion plan. Chapter page reference: 923
Question 6
Health promotion programs assist a person to advance toward optimal health. Which activity might
such programs include? Select all that apply.
Disseminating information (Disseminating information is a type of health promotion program.)
Changing lifestyle and behavior (Changing lifestyle and behavior is a type of health promotion
program.)
Prescribing medications to treat underlying disorders
Environmental control programs (Environmental control is a type of health promotion program.)
Wellness appraisal programs (Wellness appraisal is a type of health promotion program.)
Chapter number and title: 27, Health Promotion
Chapter learning objective: Identify specific health promotion strategies (including immunizations
and screenings) across the life span. Chapter page reference: 915
Question 7
Which action demonstrates how nurses promote health? Select all that apply
Role modeling (Nurses promote health by acting as role models.)
Educating patients and families (Nurses promote health by providing health education.)
Counseling (Nurses promote health by counseling.)
Providing support (Nurses promote health by providing and facilitating support.)
Providing direct care
Chapter number and title: 27, Health Promotion
Chapter learning objective: Discuss nurses’ roles in health promotion and list health promotion
activities that a nurse may conduct in acute care facilities, the workplace, local communities, and
schools. Chapter page reference: 927
Question 8
What should the nurse use to assess skin temperature?
Dorsum of the hand (The dorsum of the hand should be used to assess skin temperature.)
Pad of the fingertip
Palm of the hand
Dorsum of the wrist
Chapter number and title: 21, Physical Assessment
Chapter learning objective: Demonstrate the skills used in physical examination.
Chapter page reference: 503
,Question 9
Which statement best describes the procedure used to assess capillary refill?
Briefly press the tip of the nail with firm, steady pressure, then release and observe for
changes in color. (To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady
pressure, then release and observe for changes in skin color.)
Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the
skin for the reaction.
Tap on the skin with short strokes from your fingers.
Lift a fold of skin and allow it to return to its normal position.
Chapter number and title: 21, Physical Assessment
Chapter learning objective: Conduct a full physical examination of a client.
Chapter page reference: 541
Question 10
Based on developmental stage, how should the nurse modify the comprehensive physical
examination of an older adult?
Work rapidly to finish as quickly as possible.
Sequence the exam to limit position changes. (Because older adults may tire easily and because
they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the exam to limit
position changes.)
Demonstrate equipment before using it.
Omit portions of the exam that may be tiring.
Review: Chapter number and title: 21, Physical Assessment
Chapter learning objective: Explain adaptations that may be required when you examine
clients of various ages. Chapter page reference: 506
CONTENT QUIZ.
Question 1
Which should the RN use with a patient being admitted to the medical surgical unit after falling and
breaking their hip?
“Tell me about any allergies you have." (Three alts are closed question types of communication.
The key is open ended and can provide more data to the RN.)
“Are you allergic to any medications?”
“What foods if any are you allergic to?”
“Are you allergic to any herbs?”
Review: Types of interviews and questions in Treas, page 46
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking,
doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 451-452
Question 2
Which of these health history components will the acute care hospital RN include when doing a
comprehensive assessment on each newly admitted patient? Select all that apply.
Chief complaint
Family health history
Social history of friends
Functional ability
Medications used
Rationale: Typically, the RN will assess chief complaint, family health history, social history
of patient, functional ability, and medications used. Friends’ social history is not necessarily
pertinent.
Review: components of health history in Treas, page 46-47.
, Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking,
doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 46-47
Question 3
During an assessment of the lower extremities of a patient, the RN is not able to palpate the dorsalis
pedis pulse in the right foot. What is the next intervention the RN will implement to assess the pulse
quality?
Assess capillary refill of bilateral extremities.
Check the EHR to determine if this is a new finding.
Notify the primary care provider of assessment.
Utilize a Doppler ultrasound device to detect blood flow. ( If a pedal pulse is faint or weak, use a
Doppler ultrasound device to detect blood flow. This would be followed by assessing capillary refill,
notifying the primary care provided and documenting the findings.)
Review: Assessing dorsalis pedis pulses in Treas page, 463 (procedure 19-2D)
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking,
doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 463 (procedure 19-2D)
Question 4
The RN awakens the patient to check their BP with an automatic machine and obtains an elevated
BP reading result, while the patient has their ankles crossed in bed. What will the RN do next to
gather an accurate BP reading?
Recheck the BP again with the same equipment
Recheck the BP with another automatic machine
Take BP again, using a manual BP cuff.
Reposition the patient and recheck the BP. (Positioning the patient with legs uncrossed is
appropriate position; crossing legs can falsely elevate the BP.)
Review BP assessment steps including positioning in Treas pages 471-474.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking,
doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 471-474
Question 5
Which technique is used when the RN strikes the middle finger of the hand resting on the patient’s
abdomen with the middle finger of the dominant hand to create a sound?
Vibration
Percussion (Rationale: Percussion is the act of striking an object to produce a sound.)
Effleurage
Palpation
Review: assessment techniques in Treas, pages 503, 506.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking,
doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 503, 506
Question 6
The RN assesses a patient’s radial pulse and notes it is difficult to palpate and then disappears when
slight pressure is applied. Using the number scale associated with pulse quality, what number should
be assigned to this finding?
0
1 (Rationale: A weak pulse, rated as 1, is not easily palpated and slight pressure causes it to
disappear. A normal quality pulse (2) is easily felt; a full pulse (3) is strong and is not easily obliterated
with pressure.)
2
3
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