NUR 097 HEALTH ASSESSMENT REVIEWER (TERM 1)

The Nursing Process

1. On reviewing the patient’s care plan, the notation: “Acute pain RT post-surgical incision
as manifested by facial grimace, guarding behavior, and verbal report of pain felt in the
left lower abdominal region with pain scale of 8/10,” is an example of:
a. Assessment
b. Nursing Diagnosis
c. Planning
d. Evaluation
2. Which of the following cluster of data pertain to skin integrity of the patient? Select all
that apply.
a. Urinary and bowel incontinence
b. Overestimates ability to get up from bed
c. Bedridden, weak
d. Inadequate food intake
e. RBC and hemoglobin levels are low as shown in the laboratory results
f. Excessive sweating
3. The phase of nursing process that involves collecting, validating, organizing, and
recording data about the patient’s health status is:
a. Diagnosis
b. Planning
c. Assessment
d. Evaluation
4. Which of the following is a primary source of data?
a. The patient
b. The patient’s chart
c. The patient’s relative
d. The patient’s physician
5. Which of the following statements indicates that the student nurse is performing the
implementation phase of the nursing process?
a. The student nurse places a call light system within patient’s reach.
b. The student nurse noted that the patient is weak and needs assistance when
ambulating
c. The patient used the call light system for assistance for each need to get up from
the bed, after instruction of the student nurse
d. The student nurse documented: High risk for injury RT impaired mobility and
weakness
The Interview
6. During an interview, the patient says, “It’s so hard to stay flat on my back in the hospital
with this pregnancy. I have two more little ones at home. I’m so worried that they are not
getting the care they need.” You, as the nurse replied, “You feel worried and anxious
about your children?” This is an example of what technique of therapeutic
communication?
a. Reflection
b. Silence

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 c. Facilitation of general leads
d. Clarification
7. As much as we want to be therapeutic to the patient when conversing with them, there are
instances when non-therapeutic techniques are being used. Which of the following
statements should be avoided, except?
a. “Now, don’t worry; I’m sure you will be all right.”
b. “You said it does not hurt, but when I touched you here, you grimace.”
c. “Your doctor knows best.”
d. “You should drink your medication per orem BID.”
8. Both the nurse and the patient’s sense of spatial distance are significant throughout the
interview and physical examination. Which of the following distances indicates a
personal space?
a. 0 – 1.5 ft
b. 1.5 – 4 ft
c. 4 – 12 ft
d. 12 ft or more
9. In this phase of the interview, you will note the patient’s expectations of the disease, of
the clinician, or of health care, often based on prior personal or family experiences.
a. Pre-interview
b. Introduction
c. Working
d. Termination
Comprehensive Health History
10. When reading a medical record, you see the following documentation: Patient states, “I
have had ringing on the ears and difficulty hearing since few years ago which is
worsening, and now I am having dizziness.” This is an example of:
a. Past history
b. A review of systems
c. A functional assessment
d. A reason for seeking care
11. Which of the following statements is an appropriate documentation of a patient’s reason
for seeking help?
a. Acute episode of Meniere’s Disease, duration of 2 hours
b. Dizziness with nausea and vomiting, 2-hour duration
c. “Spinning” sensation of the body for 2 hours
d. Abnormal hearing test result
12. Which of the following is an appropriate initial question to ask to assess for intimate
pattern (domestic) violence?
a. “How are things at home?”
b. “What kind of stresses have you experienced in life, especially in the last year?”
c. “Do you feel comfortable being with your husband alone?”
d. “Does your husband have alcohol problems?”
13. It is defined as difficulty in swallowing.
a. Incontinence
b. Dysphagia
c. Polyuria

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 d. Tinnitus
14. All but one of the following data are objective data.
a. Wears eye glasses
b. Abdominal cramps
c. Watery stool
d. Weight gain of 10 pounds in a month
15. During an interview for health history, the student nurse asks, “Mrs. Leywin, what do you
do when you experience dizziness?” The student nurse is seeking which of the following
information?
a. The patient’s perception of the problem
b. Aggravating or relieving factors
c. The frequency of the problem
d. The severity of the problem
Physical Examination and Vital Signs
16. It uses tactile pressure from the palmar fingers or finger pads to assess areas of skin
elevation, depression, warmth, or tenderness; lymph nodes; pulses; contours and sizes of
organs and masses; and crepitus in the joints.
a. Inspection
b. Auscultation
c. Palpation
d. Percussion
17. Which of the following is true about obtaining the pulse of an infant, except?
a. The nurse should use the apical pulse.
b. The normal range is from 100-180bpm.
c. It should be counted before the child is disturbed for other procedures.
d. The stethoscope is placed between the child’s right nipple and sternum.
18. Student Nurse Elijah obtained a reading of 137/86mmHg after measuring the blood
pressure of his client. He is correct when he classified this as:
a. Normal BP
b. Pre-hypertension stage
c. Hypertension Stage 1
d. Hypertension Stage 2
19. The patient reports pain in the right lower quadrant of her abdomen. You remembered
that the following organs are located in the quadrant, except:
a. Liver
b. Appendix
c. Caecum
d. Right ureter
20. What breathing pattern is shown in the image?

a. Kussmaul’s breathing
b. Biot’s breathing
c. Cheyne-stoke
d. Apneustic

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 21. The mother of a 4-year-old child states that her son is having an elevated body
temperature for few days, alternated with 1 or 2 days of normal temperature. You
classified this as what type of fever?
a. Intermittent
b. Relapsing
c. Remittent
d. Constant
22. Mr. Lucas Wykes complains of pain in his amputated limb. You, as his nurse, believes
that his pain is real even though the body part he was referring to is no longer present and
that this type of pain is known as _________.
a. Phantom
b. Intractable
c. Visceral
d. Somatic
23. It is the maximum amount and duration of pain that an individual is willing to endure.
a. Pain threshold
b. Pain tolerance
c. Pain perception
d. Hyperalgesia
24. Patient Tessia Eralith has an elevated body temperature. Nurse Arthur switched on the air
conditioner to cool down the air in his client’s room and hoping to decrease her
temperature as well. This process of heat loss is known as _____.
a. Conduction
b. Convection
c. Radiation
d. Evaporation
25. It is a sensation of physical or mental hurt or suffering that causes distress or agony to the
one experiencing it.
a. Illness
b. Pain
c. Euphoria
d. Fever
Cultural and Spiritual Assessment
26. It is socially constructed concept of dividing people into populations or groups on the
basis of various sets physical characteristics.
a. Ethnicity
b. Race
c. Culture
d. Minority groups
27. The nurse has this characteristic when he recognizes the need for a set of skills necessary
to care for people of different cultures.
a. Cultural humility
b. Cultural desire
c. Cultural competence
d. Cultural Assessment

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 28. It means that most human of experiences that seeks to transcend self and find meaning
and purpose through connection with others, nature and/or a Supreme Being, which may
or may not involve religious structures or traditions.
a. Culture
b. Spirituality
c. Religion
d. None of the above
29. It is a system of beliefs or practice of worship.
a. Culture
b. Spirituality
c. Religion
d. None of the above
30. A state of suffering related to the impaired ability to experience meaning I life through
connections with self, others, the world, or a superior being.
a. Emotional damage
b. Spiritual distress
c. Religious conflict
d. Cultural gaps
Mental Status Examination
31. It is being aware of one’s existence, feelings and thoughts, and being aware of the
environment.
a. Mood
b. Affect
c. Consciousness
d. Orientation
32. Which of the following should be asked to assess the recent memory of the patient?
a. “What did you have for breakfast?”
b. “Have you ever thought of hurting yourself?”
c. “What was your first job?”
d. “When is your birthday?”
33. The patient who experiences memory problems – gives a detailed description of his
summer vacation in Boracay, although you know that he stayed at home during the entire
summer. This is an example of:
a. Blocking
b. Circumstantiality
c. Confabulation
d. Circumlocution
34. Which of the following assessment findings indicate that the patient is in stupor?
a. The patient drifts off to sleep when not stimulated.
b. The patient sleeps most of the time.
c. The patient has no response to pain or to any external or internal stimulus.
d. The patient responds only to persistent and vigorous shake or pain.
35. Which of the following is defined as a feeling of detachment or having loss of identity?
a. Depersonalization
b. Lability
c. Phobia

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 d. Rage
The Skin
36. It is an abnormal finding in the skin color wherein the patient becomes yellow-tinged;
and it suggests liver disease or excessive hemolysis of red blood cells.
a. Cyanosis
b. Carotenemia
c. Vitiligo
d. Jaundice
37. Excessive sweating is also known as __________.
a. Diaphoresis
b. Polyuria
c. Polyphagia
d. Dyspepsia
38. It is the presence of excess fluid in the interstitial spaces.
a. Dehydration
b. Edema
c. Ecchymosis
d. Petechiae
39. When you lift a fold of skin and note the ease with which it lifts up, you are assessing the
skin’s what?
a. Turgor
b. Mobility
c. Moisture
d. Temperature
40. As you assess the client’s edema, you observed a depression which is 5mm deep. You
will grade this pitting edema as _____?
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
41. What pattern of skin lesion is shown in the image below?

a. Geographic
b. Linear
c. Serpiginous
d. Arciform
42. Elevated superficial lesions 1.0 cm or larger, often formed by coalescence of papules, are
called:
a. Papule
b. Plaque
c. Nodule

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 d. Wheal
43. It can grow up to 1.0 cm, filled with serous fluid.
a. Vesicle
b. Bulla
c. Pustule
d. Burrow
The Head and Neck
44. In cushing’s syndrome, you may note facial swelling in the client’s face, particularly
these characteristics. Select all that apply.
a. Hirsutism
b. Periorbital edema
c. Moon face
d. Red cheeks
45. This facial feature is common in clients with Parkinson’s Disease.
a. Mask-like facie
b. Hirsutism
c. Moon Face
d. Buffalo hump
46. This lymph node is located at the base of the skull posteriorly.
a. Pre-auricular
b. Posterior auricular
c. Occipital
d. Tonsillar
47. What lymph node is located in the midline a few centimeters behind the tip of the
mandible?
a. Submental c. Submandibular
b. Superficial cervical d. Supraclavicular
48. To decrease the likelihood of falls, suggest the following: (Select all that apply)
a. Install safety features in the home such as grab bars in the bathroom and nonslip
mats in the bathtub.
b. Avoid the use of throw rugs.
c. Promote the use of walkers for babies
d. Remove extension or phone cords from high-traffic areas.
49. It is a category of headache that has no identifiable underlying cause.
a. Primary
b. Secondary
c. Tertiary
d. Quaternary
50. It is a type of primary headache that occurs episodically, clustered in time; several each
day for 4–8 weeks and then relief for 6–12 months.
a. Migraine
b. Tension
c. Cluster
d. Chronic headache

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