1-The nurse has a “hunch” that the patient’s elevated blood pressure is due to

pain level; however, the patient received blood pressure and pain medication
45 minutes ago. What should the nurse consider in regards to this hunch?
1. Research supports that the pain and blood pressure medications will take 30 minutes to
become effective. The nurse should wait until the next prescribed time and reevaluate pain level.
2. The nurse should consider consulting with the pain management team to evaluate the
effectiveness of the pain medication regimen.
3. The nurse should disregard the hunch because hunches are not effective at incorporating
evidence-based practices.
4. The nurse should administer pain medication based on the hunch.

2-What is the best electronic resource for incorporating evidence-based

practice into health assessment?
1. Wikipedia.org
2. Nursingworld.org
3. Mayoclinic.com
4. WebMD.com

3-A nurse working in the emergency department triage wants to apply

principles of priority setting with regard to an organizational framework for
delivery of care.
Based on your understanding of the principles of priority setting, what
categories would be included in the framework? ABC+V
4-Using this priority principle framework, how would the nurse categorize the
patients who arrived at the emergency department for treatment?
 A 48-year-old male presenting with chest pain 1st Level
 A 19-year-old female who has frequent headaches with stable vital signs
2nd Level(safety/pain)
 A 68-year-old male who had a ground-level fall (GLF) 2nd Level( Acute)
 A 5-year-old male who has a toy truck sticking out of his left ear and is playing with a toy
2nd Level (Stable vs/Chronic)
 The nurse has used clinical decision making to make her priority category assessments
for the four patients who have arrived for treatment.
-Which priority information should the nurse obtain for the 48-year-old male who has
chest pain? AMPLE and Vital Sign
-What physician orders would the nurse anticipate based on the clinical presentation for
this patient? Labwork and Chest Pain Protocol (Oxygen, Nitroglycerin, Aspirin)
-The nurse is verifying physician’s orders for the 48-year-old male patient with chest pain
when she is advised by the charge nurse that the 19year-old female patient with complaints
of frequent headaches has had a seizure. What would the nurse’s initial action be? First
Level

5-What must the nurse assess first when providing culturally competent
health care to an Asian American patient?
1. The tradition of the Asian American culture and the health care practices related to health and
wellness
2. The nurse’s heritage-based cultural values, beliefs, attitudes, and practices
3. Any differences between the nurse’s culture and the Asian American culture
4. The attitudes of Asian American cultures to the health care system in the U.S.

6-Which of these is a necessary tool for building cultural competence?

1. Cultural Competency Assessment Tool
2. Health Risk Assessment Tool
3. Ethnic Identity Tool
4. Heritage Assessment Tool

7-Which of the following would be the best way to refer to an adult patient
when initiating the interview?
1. Hello Mr. Jones, what brought you to the emergency department today?
2. Hello James, what brought you to the emergency department today?
3. Hi, I’m nurse John, what brought you into the hospital today Jim?
4. Hi Mr. J., what’s up? Why are you here today?

8-Which of the following questions would likely warrant the best response?
1. Why did you come in today?
2. Where does it hurt?
3. Have you been checking your blood pressure?
4. When was the last time you were seen by a doctor?

9-Which of the following is a good example of a well-written chief complaint?

1. Patient complaining of chest pain for about 3 days that is worse with activity and relieved with
rest.
2. Pain is a 10/10.
3. Patient complaining of chest pain. R/O MI.
4. Patient states “I don’t know what this pain is. This is the worst I have ever felt.”

10-Which of the following statements by the patient would indicate a

substance abuse problem?
1. “I have a glass of wine each day with dinner.”
2. “My wife keeps nagging me to cut down on drinking.”
3. “I love to have a few drinks around the holidays.”
4. “I have a few drinks on the weekend when my friends get together.”

11-The nurse understands that all of the following are components of the
mental status assessment except?
1. Known illness or health problem
2. Current medications known to affect mood or cognition
3. Cultural background
4. Personal history; current stress, social habits, sleep habits, and drug and alcohol use.

12-Which of the following basic functions should the nurse test first in an
assessment of mental status?
1. Behavior
2. Consciousness
3. Judgment
4. Language
13-An np student is learning about the importance of performing a mental
status assessment on patients so as to provide an adequate indicator of
cognitive status.
 What information would be included in a mental status assessment for an adult patient?
Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its
functioning is inferred through assessment of an individual's behaviors:
Consciousness: Being aware of one's own existence, feelings, and thoughts and of the
environment. This is the most elementary of mental status functions.
Language: Using the voice to communicate one's thoughts and feelings. This is a basic tool of
humans, and its loss has a heavy social impact on the individual.
Mood and affect: Both of these elements deal with the prevailing feelings; affect is a temporary
expression of feelings or state of mind, and mood is more durable, a prolonged display of
feelings that color the whole emotional life.
Orientation: The awareness of the objective world in relation to the self; ability to name own
person, place, and time.
Attention: The power of concentration, the ability to focus on one specific thing without being
distracted by many environmental stimuli.
Memory: The ability to lay down and store experiences and perceptions for later recall. Recent
memory evokes day-to-day events; remote memory brings up years' worth of experiences.
Abstract reasoning: Pondering a deeper meaning beyond the concrete and literal.
Thought process: The way a person thinks; the logical train of thought.
Thought content: What the person thinks—specific ideas, beliefs, the use of words.
Perceptions: An awareness of objects through the five senses.
 How would the np student assess abstract reasoning in an adult patient?
To test abstract reasoning in an adult patient, the nursing student would use a situation in which
the patient would have to apply or interpret a statement. Abstract reasoning involves problem
solving and interpretation of analogies. The concept can be applied both verbally and
graphically, allowing the adult patient to provide an interpretation and understanding of a process
or sequence.
 How would the np student differentiate between recent and remote memory in an adult
patient?
 to differentiate between recent and remote memory in an adult patient, the nursing student could
use probing questions related to recent/current events versus past family/childhood experiences.
The context of how the adult patient frames the information would provide the distinction
between the assessment of recent and remote memory.
 The np student is reviewing the components of a Mini Mental Status Exam (MMSE) to
be used during the assessment process. How would the student interpret the results of an
MMSE if the score was noted as 15?
The maximum score on the test is 30; people with normal mental status average 27. Scores
between 24 and 30 indicate no cognitive impairment.
Scores that occur with dementia and delirium are classified as follows: 18-23 = mild cognitive
impairment; 0-7 = severe cognitive impairment.
As the score noted is 15, this would indicate that the patient had more than just mild cognitive
impairment.

14-The student np is reviewing comparative differences between delirium and

dementia. Based on these observations, how would the student characterize
the following presentations?
➢ A 78-year-old male presents with new onset confusion in the physician’s office (Delirium)

➢ A 65-year-old female has been having continued difficulty remembering phone numbers for
several months’ duration and comes to the physician’s office out of concern (Dementia)

➢ An 89-year-old male has a urinary tract infection and is confused on admission to the hospital
(Delirium)

15-The np is assessing a patient who has been abusing opiates for 4 years. The
patient says, “I can quit anytime I want.” The np should interpret this
statement to be a sign that this individual:
1. may be in denial of needing help or having a problem with opiates.
2. is ready to quit and can do so with little intervention.
3. is motivated to enter rehabilitation.
4. should not be trusted because this individual is not of sound mind.
16-The np is caring for a patient in the ED who has been a patient many times
before in the ED. In fact, this is the patient’s second overdose in one month.
The np says, “Here we go again. I don’t know why we bother with this guy,
because he will be back out there as soon as he is discharged”. The np:
1. is not being professional and cannot give unbiased care.
2. is obligated to provide care.
3. is not obligated to provide care.
4. must find a way to come to terms with the way he or she feels about these types of issues and
work on ways to deal with them.

17-The np is assessing a patient who admits to being physically abused by her

spouse. The patient says, “I wish I would have agreed with my husband,
because then I wouldn’t have been hit.” What is the nurse’s best response?
1. “Changing your reaction to your spouse will likely change his actions against you.”
2. “Try not to blame yourself. You will know better for next time.”
3. “Your husband has to want to change. Let’s focus on you for now.”
4. “It is not your fault that your husband lost control. Changing your actions will not prevent him
from abusing you again.”

18-Which tool will assist the nurse in assessing a patient's risk for homicide?
1. Harassment in Abusive Relationships: A SelfReport Scale (HARASS)
2. Danger Assessment (DA)
3. The Abuse Assessment Screen (AAS)
4. Intimate Partner Violence (IPV) screening tool.