CHAPTER 5

1. A school nurse is teaching an adolescent girl of normal weight some of

the key factors necessary to maintain good nutrition in her teen years.
What would the nurse be correct to focus on?
A) Decreasing her calories and encouraging her to maintain her weight
to avoid obesity
B) Increasing BMI to at least 35, taking a multivitamin, and
discussing body image
C) Increasing milk intake, eating a balanced diet, and discussing
eating disorders
D) Obtaining a food diary along with providing close monitoring for
anorexia

2. During a health assessment the patient asks the nurse, "Why do you
need all this health information and who is going to see it?" What is the
nurse's best response?
A) Please do not worry. It is safe and will be used only to help us
with your care. It allows access to a wide variety of people who need to
know your health information.
B) It is good you asked and you have a right to know; your information
helps us to provide you with the best possible care, and your records are
in a secure place.
C) Your health information is placed on Web sites to provide easy
access to anyone wishing to see your medical records, which is a great
way to offer other people your information.
D) Health information becomes the property of the hospital and we will
make sure that no one sees it. Then, in 2 years, we destroy all records
and the process starts over.

3. The nurse is performing an admission assessment on a 72-year-old

female patient who speaks Spanish and broken English. How might the nurse
best collect the data?
A) Have a family member provide the data
B) Obtain the data from the old chart and physician's assessment
C) Obtain the data only from the patient
D) Collect the data from the patient and have the family provide any
missing details

4. You are the nurse assessing an 18-year-old woman. You note bruising to
the patient's upper arm that appears as fingerprints as well as yellow
bruising to the lower eye. The patient makes minimal eye contact during
the assessment. How might you best inquire about the bruising?
A) "Is anyone physically hurting you?"
B) "Tell me about your relationships."
C) "Do you want to see a social worker?"
D) "Is there something you want to tell me?"

5. You are the nurse taking a detailed assessment of a middle-aged male

patient. The man states, "The doctor has already asked me all these
questions. Why are you repeating them?" What is your best response?
A) "Taking this history allows us to determine what your needs may be
for nursing care."
B) "You are right; this may seem redundant."
C) "I want to make sure your doctor has covered everything."
D) "I am a member of your health care team."
6. You are taking a health history on a new patient. While performing
your assessment, the patient informs you that her mother has type 1
diabetes. What is the significance of this information to the health
history?
A) The patient may be at risk for developing diabetes.
B) The patient may need teaching on preventing diabetes.
C) The patient may need to attend a support group for diabetes.
D) This may affect the patient's diet during hospitalization.

7. A staff nurse is admitting a patient to her unit. During the nursing

assessment, the nurse asks the patient questions related to his
spirituality. What is the most important reason to assess a patient's
spiritual environment?
A) A patient's spiritual environment can affect his physical activity.
B) A patient's spiritual environment can affect his ability to
communicate.
C) A patient's spiritual environment can affect his quality of sexual
relationships.
D) A patient's spiritual environment can affect his responses to illness.

8. While admitting your new patient, you do a spiritual assessment. At

this time the patient indicates that he or she does not eat meat. What
would this be considered?
A) A personal choice
B) A religious practice
C) A risk for malnutrition
D) A lifestyle choice

9. You are performing a shift assessment as you begin caring for one of
your patients. What is the most effective assessment technique for the
lymph nodes of the neck?
A) Inspection
B) Auscultation
C) Palpation
D) Percussion

10. You are the clinic nurse assessing a new patient that has come in to
see a physician. The assessment data that you collect reveals that the
patient is a 23-year-old female weighing 175 pounds with a height of 5
feet 3 inches. Her body mass index is 31. What
would she be considered?
A) Average weight
B) Obese
C) Overweight
D) Underweight

11. You are completing a health assessment on a new patient! You note
that the patient has dry, dull, brittle hair and dry, flaky skin with
poor turgor. What might this indicate?
A) Excessive physical activity
B) Poor personal hygiene
C) Poor nutritional status
D) Damage from an environmental cause
12. A home care nurse is teaching a patient's daughter meal planning for
her mother who is recovering from a hip replacement surgery. Which of the
following meals indicates that the daughter understands the concept of a
nutritionally complete choice based upon the Food Guide Pyramid?
A) Cheeseburger, carrot sticks and mushroom soup with crackers
B) Spaghetti and meat sauce with a salad
C) Chicken and pepper stir fry and basmati rice
D) Ham sandwich with tomato on rye bread with peaches and yogurt

13. You are assessing a new clinic patient who has come in because of an
unintended weight loss of 10 pounds. During the assessment, you learn
that the patient has ill-fitting dentures and a limited intake of high-
fibre foods. You would be aware that the patient is at risk for what
problem?
A) Constipation
B) Dehydration
C) Malabsorption of nutrients
D) Inadequate caloric intake

14. You are teaching a nutrition education class held for a group of
older adults at a senior center. You would be sure to teach the group
that older adults have an increased need for nutrients and what?
A) A decreased need for calcium
B) An increased need for glucose
C) An increased need for sodium
D) A decreased need for calories

15. You are the nurse obtaining a health history from a patient who has
come to the local
health clinic and is having abdominal pain. You know the best question to
elicit the probable reason for the visit and identify the chief complaint
is what?
A) "Why do you think your abdomen is painful?"
B) "Where is your abdominal pain and when did it start?"
C) "What brings you to the clinic today?"
D) "What is the problem today?"

16. You are the nurse caring for a patient who is a First Nations woman
who arrives at the clinic for treatment related to type 2 diabetes. Which
question would best provide you with information about the role food
plays in the patient's cultural practice and identify how the patient's
food preferences could be related to the patient's problem?
A) "Do you feel any of your cultural practices have a negative impact
on your disease process?"
B) "What types of foods are served as a part of your cultural
practices, and how they are prepared?"
C) "As a nonnative, I am unaware of your cultural practices. Could you
teach me a few practices that may affect your care?"
D) "Tell me about foods that are important to your cultural practices
and how you feel they relate to your diabetes."
17. An 89-year-old male patient is wheelchair bound. He has been living
in a nursing home since leaving the hospital. He returns to the local
primary care clinic by wheelchair for follow-up hypertension treatment.
The nurse would modify his health history to include which question?
A) "Tell me about your medications: how they are administered and do you
take them on a regular basis?"
B) "Tell me about where you live: do you feel your needs are being
met, and do you feel safe?"
C) "Your wheelchair would seem to limit your ability to move around.
How do you deal with that?"
D) "What limitations are you dealing with related to your hypertension
and being in a wheelchair?"
Page 4

18. A 30-year-old man is in the clinic for a yearly physical. He states,

"All my uncles had heart attacks when they were young." This alerts the
nurse to complete a genetic-specific assessment. The nurse is aware that
it is important to include what as a part of a genetic-specific
assessment?
A) A complete health history including genogram along with any history of
cholesterol testing or screening and a complete physical exam
B) A limited health history along with a complete physit941apFssment
with an emphasis on genetic abnormalities
C) A limited health history and focused physical exam followed by safety-
related education
D) A family history focused on the paternal family with focused physical
exam and genetic profile

19. Your patient has a newly diagnosed heart murmur. He asks you if he
can listen to it. What would be your best response?
A) Listening is called auscultation, is done with the diaphragm, and
requires a trained ear to hear a murmur.
B) Listening is called palpation, and I would be glad to help you to
palpate your murmur.
C) Heart murmurs are pathologic and may require surgery. If you would
like to listen to your murmur, I can provide you with instruction.
D) Listening is called auscultation and should be done with both the bell
and diaphragm. If you would like to listen to your murmur, I would be
glad to help you.

20. You are performing sports physicals on healthy adolescent girls. When
it comes time to listen to the heart and lungs, you decide to what?
A) Perform auscultation with the stethoscope placed firmly over her
clothing to protect her privacy
B) Perform auscultation by holding the diaphragm lightly on her clothing
to eliminate the "scratchy noise"
C) Perform auscultation with the diaphragm placed firmly on her skin to
minimize extra noise
D) Defer the exam because she is healthy and it may agitate the girl

21. The nurse in a bariatric clinic is providing education to a patient

who wishes to lose weight. The nurse informs the patient that she has a
body mass index of 45. What does this indicate?
A) The patient is a normal weight.
B) The patient is extremely obese.
C) The patient is overweight.
D) The patient is mildly obese.

22. A nurse is conducting a home visit as part of the community health

assessment of the patient. The nurse will focus special attention on
A) availability of home health care, current Medicare rules, and
family support.
B) the community and home environment, support systems or family care,
and the availability of needed resources.
C) the future health status of the individual, and community and
hospital resources.
D) special assessment is not required; the community and acute-care
health assessments are very similar and have few distinctions.

23. You are taking a new patient's health history when the patient asks
who will have access to their information. What would be your best
response?
A) "Your information is maintained in a secure place and only those
health care professionals directly involved in your care can see it."
B) "Your information is available to anyone who works here in the
clinic."
C) "Your information is kept in computer files and anyone who gets
permission from you can see it."
D) "Your information is available to anyone who cares for you, plus your
insurance company."

24. You are admitting an elderly woman to your unit. Her husband is with
her. The husband wants to know where the information you are obtaining is
going to be kept. You explain to the husband that while his wife is in
the hospital all of her information will be kept on the computer. The
husband states, "I sure am not comfortable with that. It is too easy for
someone to break into computer records these days." What is your best
response?
A) "The Institute of Medicine has called for the implementation of the
computerized
health record so all hospitals are doing it."
B) "Don't worry, our records are very safe."
C) "This hospital is as concerned as you are about keeping our
patients' records private. So we take special precautions and we have set
up special safeguards so no one can break into our patients' medical
records."
D) "We have only had one time a patient's records were broken into in
the past 5 years so we have a pretty good record."

25. You are doing a dietary assessment with your new patient. The patient
asks you why the hospital wants to know all this information about the
way he eats. He specifically asks you, "Are you asking all these
questions because I am Middle Eastern?" What would be the most correct
response you could give this patient?
A) "We always try to abide by our patients' dietary preferences."
B) "We know that culture and religious practices often determine dietary
prohibitions, and we do not want to offend any of our patients."
C) "We wouldn't want to feed you anything you only eat on certain
holidays."
D) "We know that in some cultures certain foods are only eaten at
specific family gatherings."

26. You are orienting a new nurse to your unit. The new nurse has been
assisting an elderly woman who is Greek to fill out her menu for the next
day. Where would be a good place for you to send this new nurse to obtain
appropriate dietary recommendations for this patient?
A) Canada's Food Guide
B) Nursing resource books
C) Culturally sensitive materials such as the Mediterranean Pyramid
D) The food pagoda

27. When performing an admission assessment, the nurse knows to ask about
both first- and second-order relatives. Why does the nurse do this?
A) To see how many living relatives the patient has
B) To identify the cause of death of any aunts or uncles
C) To identify the ages of great-grandparents
D) To identify diseases that may be genetic

28. The nurse is completing a family history for a newly admitted

patient. Questions about what conditions would be included in this
assessment? (Select all that apply.)
A) Allergies
B) Alcoholism
C) Psoriasis
D) Hypervitaminosis
E) Obesity

29. The admitting nurse has just met a new patient. As the nurse
introduces himself, he begins the process of inspection on this patient.
What does the admitting nurse know it is important to do while observing
during the process of inspection?
A) Gather as much general information as possible
B) Pay attention to the details while observing
C) Write down as many details as possible during the observation
D) Not to let the patient know he is being observed

30. Palpation is a necessary skill in nursing. Many of the body's

structures, even though
they are not visible, can be assessed through palpation. Which structures
would be included in assessment by palpation?
A) Intestines
B) Muscles
C) Thyroid gland
D) Pancreas

31. What is the principle of percussion?

A) To assess the sound created by the body
B) To strike the abdominal wall with a soft object
C) To create sound over dead spaces in the body
D) To create vibration in a body wall
32. What can be assessed using percussion?
A) Borders of the heart
B) Movement of the diaphragm during expiration
C) Borders of the liver
D) Rectal distension

33. Where would a biochemical assessment of transferring be made?

A) Urine
B) Serum
C) Sputum
D) Joint fluid

34. What makes biochemical assessment such an important aspect of a

person's nutritional status?
A) It identifies abnormalities in the utilization of nutrients.
B) It predicts abnormal utilization of nutrients.
C) It reflects the tissue level of a given nutrient.
D) It predicts metabolic abnormalities in nutritional intake.

35. What is a major factor in the nutritional risk of adolescent girls?

A) Protein intake in this age group falls below recommended levels.
B) They are more physically active then at other ages.
C) Calcium intake is above the recommended levels.
D) Folate intake is below the recommended levels in this age group.

36. The teen years are not only a time of critical growth. This makes
nutritional assessment and intervention so important. What else occurs
during the teen years?
A) Lifelong eating habits are acquired.
B) Peer pressure influences growth and development.
C) Obesity develops.
D) Cultural influences become very important.

37. What assessment parameters are included when assessing a patients'

nutritional status? (Select all that apply.)
A) Ethnic mores
B) Body mass index
C) Clinical examination findings
D) Wrist circumference
E) Dietary data

38. The segment of the population who has a BMI lower than 24 have been
found to be at increased risk for poor nutritional status and its
resultant problems. What else is a low BMI associated with in the
community-dwelling elderly?
A) High risk of diabetes
B) Poor outcomes in wound healing
C) Higher mortality rate
D) Low risk of chronic disease

39. Malnutrition can be too much or too little nutrition. What can
malnutrition do in the human body?
A) Decrease risk of disease complications
B) Decrease wound healing time
C) Contribute to shorter hospital stays
D) Prolong confinement to bed

40. How does a physical assessment in the community vary in technique

from the physical assessment in the hospital?
A) A physical assessment in the community consists of the same
techniques used in the hospital.
B) A physical assessment made in the community does not require the
privacy that a physical assessment made in the hospital setting requires.
C) A physical assessment made in the community requires that the
patient be made more comfortable than would be necessary in the hospital
setting.
D) A physical assessment made in the community varies in technique from
that conducted in the hospital setting by being less structured.

41. You are conducting an assessment of a patient in her home setting.

Your patient is a 91-year-old female who lives alone and has no family
members living close by. What would you need to be aware of to aid in
providing care to this patient?
A) Where the closest relative lives
B) How to obtain Meals-on-Wheels for this patient
C) What the patient's financial status is
D) How many children this patient has
Answer Key
1. C
2. B
3.D
4.A
5.A
6.A
7.D
8. B
9.C
10. B
11. C
12.D
13.A
14.D
15. C
16.D
17. B
18.A
19.D
20. C
21. B
22. B
23.A
24. C
25. B
26. C
27.D
28. A, B, E
29. B
30. C
31.D
32.A
33. B
34. C
35.D
36.A
37. B, C,
E 38.C
39.D
40. A
41. B