5. A nurse is preforming a physical assessment of a newly admitted patient. Which patient statement
communicates subjective data?
a. “I have sores between my toes.”
b. “I dye my hair but it is really gray.”
c. “My joints hurt when I get up in the morning.”
d. “My left leg drags on the floor when I am walking.”
6. A nurse takes a patient’s blood pressure and records a diastolic pressure of 120 mm Hg. Which should
the nurse do first?
a. Notify the primary health-care provider.
b. Retake the blood pressure.
c. Notify the nurse in charge.
d. Take the other vital signs.
7. A patient had a stroke that resulted in paralysis of the right side. When clustering data, the nurse
grouped the following together: drooling of saliva and slurred speech. Which information is most
significant to include with this clustered data?
a. Receptive aphasia
b. Inability to ambulate
c. Difficulty swallowing
d. Incontinence of bowel movements
, Rest Answers KEY on last page
8. A patient who experienced a stroke has left-sided hemiparesis and is incontinent of urine. Which is an
appropriately worded nursing diagnosis for this patient?
a. The patient has a need to maintain skin integrity.
b. The patient has a stroked evidenced by hemiparesis and incontinence.
c. The patient will be clean and dry and will receive range-of-motion exercises every four hours.
d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and
incontinence.
9. A nurse uses the interviewing process of clarification when interviewing a patient. Which is the nurse
doing when this communication technique is used?
a. Paraphrasing the patient’s message
b. Restating what the patient has said
c. Reviewing the patient’s communication
d. Verifying what is implied by the patient
10. A patient has dependent edema of the ankles and feet and is obese. Which diet should the nurse
expect the primary health-care provider to order?
a. Low in sodium and high in fat
b. Low in sodium and low in calories
c. High in sodium and high in protein
d. High in sodium and low in carbohydrates
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