Nursing Assessment and Diagnosis
Final Test Solutions
Course Introduction
Nursing Assessment and Diagnosis is a foundational course that equips students with the knowledge and skills needed to systematically collect comprehensive patient data and accurately identify health problems. Through theoretical instruction and practical application, students learn to conduct holistic health assessments utilizing various techniques such as observation, interview, physical examination, and diagnostic reasoning. The course emphasizes the use of critical thinking in analyzing assessment data to formulate precise nursing diagnoses, which serve as the basis for planning individualized patient care. Students also explore the use of standardized classification systems and documentation strategies to communicate assessment findings effectively within the healthcare team.
Recommended Textbook
Physical Examination and Health Assessment 5th Edition by Carolyn Jarvis
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30 Chapters
966 Verified Questions
966 Flashcards
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Chapter 1: Critical Thinking in Health Assessment
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34 Verified Questions
34 Flashcards
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Sample Questions
Q1) Why is the concept of prevention essential in describing health?
A)Disease can be prevented by treating the external environment.
B)The majority of deaths among Americans under age 65 years are not preventable.
C)Prevention places emphasis on the link between health and personal behavior.
D)The means to prevention is through treatment provided by primary health care practitioners.
Answer: C
Q2) B = second-level priority problem
A)A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
B)A teenager who was stung by a bee during a soccer match is having trouble breathing.
C)An older adult with a urinary tract infection is also showing signs of confusion and agitation.
Answer: C
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Chapter 2: Developmental Tasks and Health Promotion
Across the Life Cycle
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34 Verified Questions
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Sample Questions
Q1) An adolescent is beginning to develop the ability to deal with hypothetical situations and abstract thinking.The nurse would consider this finding:
A)advanced for this patient's age.
B)an expected finding only in the elderly.
C)a normal finding during this stage of development.
D)abnormal because abstract thinking should begin to take place in early childhood.
Answer: C
Q2) Which of the following statements best characterizes resolution of Erikson's last ego stage,integrity versus despair?
A)The individual becomes more interested in society's extrinsic rewards.
B)The individual experiences a loss of recognition and authority.
C)The adult feels the need to pursue youthful activities as a culmination of life experiences.
D)The adult feels satisfied that if it were possible to do it over again,he or she would live it the same way.
Answer: D
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Chapter 3: Cultural Competence: Cultural Care
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Sample Questions
Q1) A 63-year-old Chinese-American man enters the hospital with complaints of chest pain,shortness of breath,and palpitations.Which statement most accurately reflects the nurse's best course of action?
A)The focus should be a full cardiac assessment.
B)He may be having difficulty after learning of his wife's cancer and is expressing psychosomatic complaints.
C)This patient is not in any danger at present and should be sent home with instructions to contact his physician.
D)It is unclear what is happening with this patient and his assessment should include physical and psychosocial realms.
Answer: D
Q2) Categories such as ethnicity,gender,and religion illustrate the concept of: A)family. B)cultures.
C)spirituality. D)subcultures.
Answer: D
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Page 5
Chapter 4: The Interview
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Sample
Questions
Q1) A female patient does not speak English well,and the nurse needs to choose an interpreter.Which of the following would be the most appropriate choice?
A)A trained interpreter
B)A male family member
C)A female family member
D)A volunteer college student from the foreign language studies department.
Q2) A patient has finished giving the nurse information about the reason he is seeking care.When reviewing the data,the nurse finds that some information about past hospitalizations is missing.Which statement by the nurse would be most appropriate to gather these data?
A)"Mr.Y. ,at your age,surely you have been hospitalized before!"
B)"Mr.Y. ,I just need permission to get your medical records from County Medical."
C)"Mr.Y. ,you mentioned that you have been hospitalized on several occasions.Would you tell me more about that?"
D)"Mr.Y. ,I just need to get some additional information about your past hospitalizations.When was the last time you were admitted for chest pain?"
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6
Chapter 5: The Complete Health History
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Sample Questions
Q1) The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities.Which of the following questions would be appropriate to use to assess health promotion activities for this patient?
A)"Do you perform testicular self-exams?"
B)"Have you ever noticed any pain in your testicles?"
C)"Have you had any problems with passing your urine?"
D)"Do you have any history of sexually transmitted disease?"
Q2) A patient tells the nurse that she has had abdominal pain for the past week.What would be the best response by the nurse?
A)"Can you point to where it hurts?"
B)"We'll talk more about that later in the interview."
C)"What have you had to eat in the last 24 hours?"
D)"Have you ever had any surgeries on your abdomen?"
Q3) The review of systems provides the nurse with:
A)physical findings related to each system.
B)information regarding health promotion practices.
C)an opportunity to teach the patient medical terms.
D)information necessary for the nurse to diagnose the patient's medical problem.
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Page 7
Chapter 6: Mental Status Assessment
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Sample Questions
Q1) The nurse has decided to administer the Set Test to Mr.C. ,70.To administer this test the nurse needs to:
A)ask him to name 10 fruits,animals,colors,and towns.The nurse will tell him that he or she will be available to help if he gets stuck.
B)ask him to name 10 items based on the categories in the acronym FACT.The nurse will tell him that there is no hurry to do this.
C)ask him to name 10 items based on the categories in the acronym FACT.If he has difficulty,the nurse may prompt his memory.
D)ask him to name 10 items based on the categories in the acronym FACT.Tell him this test is timed and he can only have 2 minutes to take it.
Q2) When assessing aging adults,the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
A)the presence of phobias.
B)their general intelligence.
C)the presence of irrational thinking patterns.
D)their sensory-perceptive abilities.
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Chapter 7: Domestic Violence Assessment
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11 Verified Questions
11 Flashcards
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Sample Questions
Q1) When documenting intimate partner violence and elder abuse,the nurse should include:
A)photographic documentation of injuries.
B)a summary of the abused patient's statements.
C)verbatim documentation of every statement made.
D)a general description of injuries in the progress notes.
Q2) During an examination,the nurse notices a patterned injury on a patient's back.Which of the following would cause such an injury?
A)Blunt force
B)Friction abrasion
C)Stabbing from a kitchen knife
D)Whipping from an extension cord
Q3) When assessing bruising,which color indicates a new bruise that is less than 2 hours old?
A)Red
B)Purple-blue
C)Greenish-brown
D)Brownish-yellow
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Chapter 8: Assessment Techniques and the Clinical Setting
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Sample Questions
Q1) A 6-month-old infant has been brought to the well-child clinic for a check-up.She is currently sleeping.What should the examiner do first?
A)Auscultate the lungs and heart while the infant is still sleeping.
B)Examine the infant's hips because this procedure is uncomfortable.
C)Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
D)Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
Q2) Fingertips
A)Should be used to detect the shape and consistency of a mass in the axilla
B)Best for evaluating the skin texture over the abdomen.
C)Used to determine the temperature of the patient's skin.
D)Best for detecting vibration over the thorax and abdomen.
Q3) When examining the aging adult,the nurse should:
A)avoid touching the patient too much.
B)attempt to perform the entire physical during one visit.
C)speak loudly and slowly because most aging adults have hearing deficits.
D)arrange the sequence to allow as few position changes as possible.
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10
Chapter 9: General Survey, measurement, vital Signs
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Sample Questions
Q1) A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm.The nurse would:
A)refer the infant to a physician for further evaluation.
B)consider this a normal finding for a 1-month-old infant.
C)expect the chest circumference to be greater than the head circumference.
D)ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
Q2) When assessing a 75-year-old patient who has asthma,the nurse notes that he assumes a tripod position,leaning forward with arms braced on the chair.On the basis of this observation,the nurse would:
A)assume that the patient is eager and interested in participating in the interview.
B)evaluate the patient for abdominal pain,which may be exacerbated in the sitting position.
C)assume that the patient is having difficulty breathing and assist him to a supine position.
D)recognize that a tripod position is often used when a patient is having respiratory difficulties.
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11
Chapter 10: Pain Assessment: the Fifth Vital Sign
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Sample Questions
Q1) The nurse is assessing a patient's pain.The nurse knows that which of the following is considered the most reliable indicator of pain?
A)Vital signs
B)The physical examination
C)Computerized axial tomography scan findings
D)The subjective report
Q2) A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale.Which of the following assessment findings indicates an acute pain response to poorly controlled pain?
A)Confusion
B)Hyperventilation
C)Increased blood pressure and pulse
D)Decreased blood pressure and pulse
Q3) When assessing a patient's pain,the nurse knows that an example of visceral pain would be:
A)hip fracture.
B)cholecystitis.
C)second-degree burns.
D)pain after a leg amputation.
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Page 12
Chapter 11: Nutritional Assessment
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32 Flashcards
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Sample Questions
Q1) A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss.The nurse determines that many of her complaints may be related to erratic eating patterns,eating predominantly fast foods,and high caffeine intake.In this situation,which of the following is most appropriate when collecting current dietary intake information?
A)Schedule a time for direct observation of the adolescent during meals.
B)Ask the patient for a 24-hour diet recall and assume this is reflective of a typical day for her.
C)Have the patient complete a food diary for 3 days-2 weekdays and 1 weekend day.
D)Use the food frequency questionnaire to identify the amount of intake of specific foods.
Q2) A patient tells the nurse that his food just doesn't have any taste anymore.The nurse's best response would be:
A)"That must be really frustrating."
B)"When did you first notice this change?"
C)"My food doesn't always have a lot of taste either."
D)"Sometimes that happens but your taste will come back."
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Page 13
Chapter 12: Skin, hair, and Nails
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Sample Questions
Q1) A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors.The nurse will encourage her to stop trying to remove the corn with her scissors because:
A)the woman could be at increased risk for infection and lesions because of her chronic disease.
B)with her diabetes,she has increased circulation to her foot and it could cause severe bleeding.
C)she is 75 years old and is unable to see,so she puts herself at greater risk for self-injury with the scissors.
D)with her peripheral vascular disease,her range of motion is limited and she may not be able to reach the corn safely.
Q2) A patient comes in for a physical,and she complains of "freezing to death" while waiting for her examination.The nurse notes that her skin is pale and cool and attributes this finding to:
A)venous pooling.
B)peripheral vasodilation.
C)peripheral vasoconstriction.
D)decreased arterial perfusion.
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) The physician reports that a patient has a tracheal shift.The nurse is aware that this means that the patient's trachea is:
A)pulled to the affected side with systole.
B)pushed to the unaffected side with a tumor.
C)pulled to the unaffected side with plural adhesions.
D)pushed to the affected side with thyroid enlargement.
Q2) During a well-baby checkup,a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position.Which response by the nurse is appropriate?
A)"Head control is usually achieved by 4 months of age."
B)"You shouldn't be trying to pull your baby up like that until she is older."
C)"This is a concern because head control should be achieved by this time."
D)"This is a concern because it indicates possible nerve damage to the neck muscles."
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15
Chapter 14: Eyes
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32 Flashcards
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Sample Questions
Q1) When examining the eye,the nurse is aware that the bulbar conjunctiva:
A)overlies the sclera.
B)covers the iris and pupil.
C)is visible at the inner canthus of the eye.
D)is a thin mucous membrane that lines the lids.
Q2) The nurse is testing a patient's visual accommodation,which refers to:
A)pupillary constriction when looking at a near object.
B)pupillary dilation when looking at a far object.
C)changes in peripheral vision in response to light.
D)involuntary blinking in the presence of bright light.
Q3) In assessing the sclera of a black patient,which of the following would be an expected finding?
A)Yellow fatty deposits over the cornea
B)Pallor near the outer canthus of the lower lid
C)Yellow color of the sclera that extends up to the iris
D)The presence of small brown macules on the sclera
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Chapter 15: Ears
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Sample Questions
Q1) The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident.Which of the following statements indicates the most important reason for assessing for any drainage from the canal?
A)If the drum has ruptured,there will be purulent drainage.
B)Bloody or clear watery drainage can indicate a basal skull fracture.
C)The auditory canal many be occluded from increased cerumen.
D)There may be occlusion of the canal caused by foreign bodies from the accident.
Q2) Which of the following statements concerning the eustachian tube is true?
A)It is responsible for the production of cerumen.
B)It remains open except when swallowing or yawning.
C)It allows passage of air between the middle and outer ear.
D)It helps equalize air pressure on both sides of the tympanic membrane.
Q3) A patient has been shown to have a sensorineural hearing loss.During the assessment,it would be important for the nurse to:
A)speak loudly so he can hear the questions.
B)assess for middle ear infection as a possible cause.
C)ask the patient what medications he is currently taking.
D)look for the source of the obstruction in the external ear.
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Chapter 16: Nose, mouth, and Throat
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Sample Questions
Q1) A patient comes into the clinic complaining of facial pain,fever,and malaise.On examination,the nurse notes swollen turbinates and purulent discharge from the nose.The patient also complains of a dull,throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas.The nurse recognizes that this patient has:
A)posterior epistaxis.
B)frontal sinusitis.
C)maxillary sinusitis.
D)nasal polyps.
Q2) When examining the nares of a 45-year-old patient who has complaints of rhinorrhea,itching of the nose and eyes,and sneezing,the nurse notes the following: pale turbinates,swelling of the turbinates,and clear rhinorrhea.Which of the following is most likely the cause?
A)Nasal polyps
B)Acute sinusitis
C)Allergic rhinitis
D)Nasal carcinoma
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Chapter 17: Breasts and Regional Lymphatics
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Sample Questions
Q1) A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination.She is concerned about changes in her breasts that she has noticed over the past 5 years.She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be:
A)"This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues."
B)"This is a normal change that occurs as women get older.It is due to the increased levels of progesterone during the aging process."
C)"Decreases in progesterone and estrogen after menopause causes atrophy of the glandular tissue in the breast.This is a normal process of aging."
D)"Postural changes in the spine make it appear that your breasts have changed in shape.Exercises to strengthen the muscles of the upper back and chest wall will help to prevent the changes in elasticity and size."
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19
Chapter 18: Thorax and Lungs
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Sample Questions
Q1) A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe.What is the nurse's best reply?
A)"The diaphragm becomes fixed during pregnancy,making it difficult to take in a deep breath."
B)"The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe."
C)"What you are experiencing is normal.Some women may interpret this as shortness of breath,but it is a normal finding and nothing is wrong."
D)"This is normal as the fetus grows because of the increased oxygen demand on the mother's body and results in an increased respiratory rate."
Q2) When performing a respiratory assessment on a patient,the nurse notes a costal angle of approximately 90 degrees.This characteristic is:
A)seen in patients with kyphosis.
B)indicative of pectus excavatum.
C)a normal finding in a healthy adult.
D)an expected finding in a patient with a barrel chest.
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Page 20
Chapter 19: Heart and Neck Vessels
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Sample Questions
Q1) A 45-year-old man is in the clinic for "a routine physical." During the history the patient states he's been having difficulty sleeping."I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be:
A)"When was your last electrocardiogram?"
B)"It's probably because it's been so hot at night."
C)"Do you have any history of problems with your heart?"
D)"Have you had a recent sinus infection or upper respiratory infection?"
Q2) The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees.The nurse knows that this finding indicates:
A)decreased fluid volume.
B)increased cardiac output.
C)narrowing of jugular veins.
D)increased pressure in the right side of his heart.
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21
Chapter 20: Peripheral Vascular System and Lymphatic System
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Sample Questions
Q1) Which of the following pulses would most likely be seen in an individual with untreated hyperthyroidism?
A)A normal pulse
B)An absent pulse
C)A bounding pulse
D)A weak,thready pulse
Q2) Which of the following statements is true regarding assessment of the ankle-brachial index (ABI)?
A)Normal ABI indices are from 0.50 to 1.0.
B)The normal ankle pressure is slightly lower than the brachial pressure.
C)The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals.
D)An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication.
Q3) The nurse uses the "profile sign" to detect:
A)pitting edema.
B)early clubbing.
C)symmetry of the fingers.
D)insufficient capillary refill.
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Chapter 21: Abdomen
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Sample Questions
Q1) While examining a patient,the nurse observes abdominal pulsations between the xiphoid and umbilicus.The nurse would suspect that these are:
A)pulsations of the renal arteries.
B)pulsations of the inferior vena cava.
C)normal abdominal aortic pulsations.
D)increased peristalsis from a bowel obstruction.
Q2) The incidence of lactose intolerance is higher in adults of which ethnic group?
A)American Indians
B)Hispanics
C)Whites of British descent
D)Americans of northern European descent
Q3) When palpating the abdomen of a 20-year-old patient,the nurse notes the presence of tenderness in the left upper quadrant with deep palpation.Which of the following structures is most likely to be involved?
A)Spleen
B)Sigmoid
C)Appendix
D)Gallbladder
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Chapter 22: Musculoskeletal System
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Sample Questions
Q1) A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain.The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus.This shift in posture is known as:
A)lordosis.
B)scoliosis.
C)ankylosis.
D)kyphosis.
Q2) When performing a musculoskeletal assessment,the nurse knows that the correct approach for the examination should be:
A)proximal to distal.
B)distal to proximal.
C)posterior to anterior.
D)anterior to posterior.
Q3) Of the 33 vertebrae in the spinal column,there are:
A)5 lumbar.
B)5 thoracic.
C)7 sacral.
D)12 cervical.
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Page 24
Chapter 23: Neurologic System
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Sample Questions
Q1) A 59-year-old patient a herniated intervertebral disk.Which of the following findings would the nurse expect to see on physical assessment of this individual?
A)Hyporeflexia
B)Increased muscle tone
C)A positive Babinski's sign
D)The presence of pathologic reflexes
Q2) In assessing a 70-year-old patient who has had a recent cerebrovascular accident,the nurse notes right-sided weakness.What might the nurse expect to find when testing his reflexes on the right side?
A)Lack of reflexes
B)Normal reflexes
C)Diminished reflexes
D)Hyperactive reflexes
Q3) The two parts of the nervous system are the:
A)motor and sensory.
B)central and peripheral.
C)peripheral and autonomic.
D)hypothalamus and cerebral.
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Chapter 24: Male Genitourinary System
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Sample Questions
Q1) During an examination of an aging male,the nurse recognizes that normal changes to expect would be:
A)a change in scrotal color.
B)a decrease in the size of the penis.
C)enlargement of the testes and scrotum.
D)an increase in the number of rugae over the scrotal sac.
Q2) The nurse is performing a genital examination on a male patient and notes urethral drainage.When collecting urethral discharge for microscopic examination and culture,the nurse should:
A)ask the patient to urinate into a sterile cup.
B)ask the patient to obtain a specimen of semen.
C)insert a cotton-tipped applicator into the urethra.
D)compress the glans between the examiner's thumb and forefinger and collect any discharge.
Q3) The nurse is examining the glans and knows that which of the following is a normal finding for this area?
A)The dorsal vein may be visible.
B)Hair is without pest inhabitants.
C)The skin is wrinkled and without lesions.
D)Smegma may be present under the foreskin of an uncircumcised male.
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Chapter 25: Anus,rectum,and Prostate
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Sample Questions
Q1) A 13-year-old girl is visiting the clinic for a sports physical.The nurse should remember to include which of the following in the examination?
A)Test for occult blood
B)The Valsalva maneuver
C)Internal palpation of the anus
D)Inspection of the perianal area
Q2) Which of the following statements about the anal canal is true?
A)The anal canal is about 2 cm long in the adult.
B)The anal canal slants backward toward the sacrum.
C)The anal canal contains hair and sebaceous glands.
D)The anal canal is the outlet for the gastrointestinal tract.
Q3) While performing a rectal examination,the nurse notes a firm,irregularly shaped mass.What should the nurse do next?
A)Continue with exam and note finding in chart.
B)Instruct patient to return for repeat assessment in 1 month.
C)Tell the patient that a mass was felt but it is nothing to worry about.
D)Report the finding and refer the patient to a specialist for further examination.
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Chapter 26: Female Genitourinary System
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Sample Questions
Q1) A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination.Which of the following should the nurse include in patient education?
A)A postmenopausal woman is not at any greater risk for heart disease than a younger woman is.
B)A postmenopausal woman should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions.
C)A postmenopausal woman has only stopped menstruating;there really are no other significant changes that she should be concerned with.
D)A postmenopausal woman is likely to have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle.
Q2) When observing the vestibule,the nurse should be able to see the:
A)urethral meatus and vaginal orifice.
B)vaginal orifice and vestibular (Bartholin's)glands.
C)urethral meatus and paraurethral (Skene's)glands.
D)paraurethral (Skene's)and vestibular (Bartholin's)glands.
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28
Chapter
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Sample Questions
Q1) After the examination of an infant,the nurse notes opisthotonos.The nurse recognizes that this finding often occurs with:
A)cerebral palsy.
B)meningeal irritation.
C)lower motor neuron lesion.
D)upper motor neuron lesion.
Q2) While the nurse palpates the maxillary sinuses,the patient tells the nurse that he has some tenderness in that area.The nurse should proceed by:
A)tapping on the sinus area.
B)auscultating the sinus area.
C)asking him to blow his nose.
D)transilluminating the sinuses.
Q3) A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing.I have to sit up in bed to get a good breath." When documenting this information,the nurse would note:
A)orthopnea.
B)acute emphysema.
C)paroxysmal nocturnal dyspnea.
D)acute shortness of breath episode.
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Chapter 28: Reassessment of the Hospitalized Adult
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Q1) What should the nurse assess before entering the patient's room on morning rounds?
A)Posted conditions,such as isolation precautions
B)The patient's input and output chart from the previous shift
C)The patient's general appearance
D)The presence of any visitors in the room
Q2) When assessing the neurologic system of a hospitalized patient during morning rounds,the nurse will include which of the following?
A)Blood pressure
B)The patient's rating of pain on a 1 to 10 scale
C)The patient's ability to communicate
D)The patient's personal hygiene level
Q3) When assessing a patient's general appearance,the nurse will include which of the following?
A)Is the patient's muscle strength equal in both arms?
B)Is ptosis or facial droop present?
C)Does the patient respond appropriately to questions?
D)Are the pupils equal in reaction and size?
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Chapter 29: The Pregnant Female
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Sample Questions
Q1) The nurse is palpating the abdomen of a woman who is 35 weeks' pregnant and notes that the fetal head is facing downward toward the pelvis.The nurse would document this as:
A)fetal lie.
B)fetal variety.
C)fetal attitude.
D)fetal presentation.
Q2) A 25-year-old woman is in the clinic for her first prenatal visit.Which laboratory screening is appropriate at this time?
A)Human chorionic gonadotropin
B)Complete blood cell count
C)Alpha-fetoprotein
D)Carrier screening for cystic fibrosis
Q3) During the assessment of a woman in her 22nd<sup> </sup>week of pregnancy,the nurse is unable to hear fetal heart tones with the Doppler device.The nurse should:
A)wait 10 minutes and try again.
B)notify the physician immediately.
C)use a fetoscope to identify fetal heart tones.
D)use ultrasound to verify cardiac activity.
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Chapter 30: Functional Assessment of the Older Adult
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Q1) During a morning assessment,the nurse notices that an older patient is less attentive and is unable to recall yesterday's events.The nurse administers the Mini Mental State Examination,which will screen for:
A)dementia.
B)depression.
C)delirium.
D)psychosis.
Q2) An 85-year-old man has been hospitalized after a fall at home,and his 86-year-old wife is at his bedside.She tells the nurse that she is his primary caregiver.The nurse should assess the caregiver for signs of possible caregiver burnout,such as:
A)depression.
B)weight gain.
C)hypertension.
D)social phobias.
Q3) Which statement about the Lawton IADL instrument is true?
A)The nurse uses direct observation to implement this tool.
B)It is designed as a self-report measure of performance rather than ability.
C)It is not useful in the acute hospital setting.
D)It is best used for those residing in an institutional setting.
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