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nsg 316 final only for jentifer/120 Exam Questions and Answers
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nsg 316 final only for jentifer/120Exam Questions and Answers
What are the elements of a general survey and health assessment?
a. physical appearance, body structure, mobility, behavior, and
measurement
b. head to toe assessment, mental status, mobility, ADLs
c. physical appearance, ADLs, behavior, body structure
d. body structure, mobility, head to toe assessment, measurement - -a
physical appearance, body structure, mobility, behavior, and measurement
-A nurse is caring for a client who asks about measures the nurse takes to
protect client privacy. Which of the following is an appropriate response by
the nurse?
a. "I will provide their information to anyone who requests it."
b. "I will make sure my password to log into the system is the same one I use
for everything else."
c. "I will talk to my friends about the client in order to get advice."
d. "I will log off the computer in between seeing clients." - -d
HIPAA establishes national standards for the protection of certain health info.
The privacy rule can be violated if a client's health info is on the computer
screen and the nurse leaves it up while taking care of other clients.
-Which of these are components of a functional assessment? (Select all that
apply)
a. vision and hearing
b. mobility
c. continence
d. nutrition
e. ADL-IADL - -all of them
A functional assessment also includes mental status, affect, home
environment, and social support!
-FICA is an assessment tool used to determine a patient's spiritual history.
What does FICA stand for? - -F = faith
I = importance/influence
C = community
A = address/action
-What are the four sources of pain? (Provide some examples for each) - -1.
Visceral pain = large interior organs (e.g., appendicitis, gallstones)
,2. Deep somatic pain = blood vessels, joints, tendons, muscles, and bone
injury (e.g., sprain, broken bone)
3. Cutaneous pain = skin surface and subcutaneous tissues (e.g., paper cut)
4. Referred pain = felt at a particular site but originates from another
location (e.g., left arm hurting during an MI although the issue is with the
heart)
-A patient is crying and says, "Please get me something to relieve this pain."
What should the nurse do next?
a. Verify that the patient has an order for pain medications and administer
order as directed
b. Assess the level of pain and ask patient what usually works for his or her
pain, administer pain medication as needed, then reassess pain level
c. Assess the level of pain and give medications according to pain level, and
then reassess pain
d. Reposition the patient, then reassess the pain after intervention - -b
Assess the level of pain and ask patient what usually works for his or her
pain, administer pain medication as needed, then reassess pain level
Answers A, C, and D are incorrect because pain management should be
collaborative, and the patient is not part of the decision making process in
these answers.
-Pain is always ____?
a. subjective
b. objective
c. observed in clinical findings
d. backed up with data - -a
subjective
-A patient with a severe muscle cramp tells the nurse, "The pain is a little
better when I massage the muscle or apply a cold pack." Which criterion of
the PQRST method of pain assessment is addressed in the patient's
statement?
a. Severity Scale
b. Quality/Quantity
c. Region/Radiation
d. Provocation/Palliation - -d
provocation/palliation
PQRST is a pain assessment scale; it stands for Provocation/Palliation,
Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the
patient is describing methods that provide comfort and relieve the pain, it
, indicates that the patient is addressing Provocation/Palliation. If the patient
reports about severity of pain on a scale of 0 to 10, then it indicates that the
patient is addressing Severity. When addressing the Quality/Quantity of the
pain, the patient describes the pain felt. If the patient reports about the site
of pain, then the patient is addressing Region/Radiation.
-Test for CN XI
a. light tight dynamite
b. shrug shoulders, ROM with and without resistance in the neck
c. test if uvula rises with phonation
d. test if patient feels sensation on the trigeminal areas of the face - -b
shrug shoulders, ROM with and without resistance in the neck
-Test for CN IX
a. light tight dynamite
b. shrug shoulders, ROM with and without resistance in the neck
c. test if uvula rises with phonation
d. test if patient feels sensation on the trigeminal areas of the face - -c
test if uvula rises with phonation
-Test for CN XII
a. light tight dynamite
b. shrug shoulders, ROM with and without resistance in the neck
c. test if uvula rises with phonation
d. test if patient feels sensation on the trigeminal areas of the face - -a
light tight dynamite
-If a patient presents equal anterior-posterior- to- traverse ratio, what would
it be indicative of?
a. pectus excavatum
b. scoliosis
c. kyphosis
d. barrel chest - -d
barrel chest
-What lung sounds would present as adventitious? (select all that apply)
a. Stridor
b. Wheezes
c. Bronchi
d. Rhonchi
e. Rales - -a, b, d, e
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