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    Exam Review

    1. During a health history intake, the client avoids eye contact and answers questions briefly. What should the nurse prioritize understanding the client's needs?
      A)Conclude that the client is simply shy and proceed with a brief assessment
      B)Ask the client why they are withholding information
      C)Report the client's behavior to the healthcare team immediately
      D)Use clarifying questions to explore their concerns in a respectful manner
    2. Which method is most appropriate for assessing a patient's level of consciousness?
      A)Monitor verbal response to orientation questions
      B)Assess gait while walking
      C)Ask them to shake hands
      D)Observe facial expressions
    3. A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?
      A)A client who is receiving enteral feeding and can change position independently
      B)A client who is unresponsive to verbal commands and changes position occasionally
      C)A client who makes frequent slight changes in position and walks occasionally
      D)A client who is alert and responsive and eats 25% of each meal
    4. When conducting a physical assessment what skin finding requires further investigation for underlying liver disease?
      A)Pale skin tone
      B)Yellowish skin color
      C)Bluish extremities
      D)Reddened skin appearing inflamed
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    Exam Review

    1. Which assessment technique is used by a nurse to verify the presence of bruits in the abdominal area?
      A)Palpation
      B)Auscultation
      C)Inspection
      D)Percussion
    2. In a focused health assessment how does the nurse determine the priority data to collect from a patient?
      A)Based on standardized health questionnaires only
      B)Following an identical template for each patient
      C)By completing a general check of all systems
      D)Based on the patient's expressed concerns and medical history
    3. A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs. Which ethical principle is most applicable here?
      A)Confidentiality
      B)Beneficence
      C)Justice
      D)Autonomy
    4. During an abdominal assessment of a patient a nurse auscultates first after inspection. Why is this sequence important?
      A)Auscultation provides the baseline for further assessment
      B)It prevents altering bowel sounds
      C)Palpation is more likely to detect abnormalities after auscultation
      D)Inspection may reveal abnormalities that require auscultation
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    Exam Review

    1. What is the likely outcome if the abdominal assessment sequence is incorrectly performed starting with palpation?
      A)Enhanced patient comfort during examination
      B)No impact on examination results
      C)Potential misinterpretation of bowel sounds
      D)Increased accuracy of bowel sound determination
    2. A nurse is performing a health assessment and notices the client is tearful and indecisive when answering questions. What therapeutic communication technique is most appropriate for the nurse to use in this situation?
      A)Active listening
      B)Therapeutic silence
      C)Sharing information
      D)Clarifying questions
    3. A nurse is conducting a health assessment. To build rapport with the client which strategy is most effective?
      A)Maintaining professional distance to avoid emotional involvement
      B)Making frequent jokes to lighten the mood
      C)Using therapeutic communication techniques like empathy and active listening
      D)Directly asking only about the clients medical condition without engaging personally
    4. A charge nurse is teaching a newly licensed nurse about accessing a clients medical records. Which of the following should the nurse include?
      A)A nurse can access the records of any client in the healthcare facility, as long as the information is not shared
      B)A nurse can only share information from the clients medical record with immediate family members
      C)A nurse can only access the records of clients they are actively caring for
      D)A nurse can share information about a client with clients who have a similar diagnosis
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    Exam Review

    1. A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
      A)Intact skin with localized erythema
      B)Full-thickness skin loss with visible adipose tissue
      C)Full-thickness skin loss with visible bone
      D)Partial-thickness skin loss with red tissue in wound bed
    2. When conducting a focused health assessment, which scenario requires immediate prioritization?
      A)A patient reporting a recent change in hair color
      B)A patient requesting routine medication refills
      C)A patient exhibiting acute chest pain
      D)A patient with a persistent low-grade fever
    3. Which layer of the skin is primarily responsible for temperature regulation and cushioning of the internal organs?
      A)Dermis
      B)Stratum corneum
      C)Epidermis
      D)Subcutaneous layer
    4. Which layer of the skin is primarily responsible for temperature regulation through insulation?
      A)Epidermis
      B)Subcutaneous layer
      C)Dermis
      D)Stratum corneum
    Page 4 of 13

    Exam Review

    1. While assessing capillary refill in a patient's nailbed, you observe that the refill time is 4 seconds. What should be your priority action?
      A)Reassess capillary refill in another finger and compare findings
      B)Apply a warm compress to improve circulation
      C)Document findings and proceed with the assessment using the finger probe
      D)Immediately notify the provider of poor perfusion
    2. Which therapeutic communication technique is most appropriate when a client mentions they feel misunderstood by their family?
      A)State that it is normal to feel that way and proceed with standard assessment tasks
      B)Request that the client elaborate after the assessment is completed
      C)Provide advice based on the nurse's own experience
      D)Validate their feelings by acknowledging their statement empathetically
    3. When conducting a health assessment for a pediatric client, the nurse notes that the child avoids eye contact, and the parents answer many questions on the child's behalf. What primary action should the nurse take to ensure effective communication?
      A)Focus only on the parents' responses during the interaction
      B)Use open-ended questions to engage the child directly
      C)Provide information on pediatric care to the parents
      D)Ask closed-ended questions to obtain more direct answers from the parents
    4. When a nurse uses personal discretion to share patient information with colleagues without consent which ethical principle is violated?
      A)Nonmaleficence
      B)Confidentiality
      C)Beneficence
      D)Justice
    Page 5 of 13

    Exam Review

    1. Which action would a nurse take when documenting a patient's affect that appears discordant with the rest of their mood?
      A)Exclusively document verbal behavior
      B)Document both affect and mood and any discrepancies
      C)Separate the documentation into two different entries
      D)Only describe the patient's current affect
    2. When documenting skin color in EHR, which factor is least likely to affect your documentation?
      A)Recent physical activity
      B)Patient’s health condition
      C)Lighting in the examination room
      D)The patient's clothing
    3. A nurse is admitting a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
      A)Use an electronic translating service from the Internet to interpret the information
      B)Telephone the interpreter that is designated for the facility to interpret the information
      C)Ask the client's partner to interpret the information
      D)Call a nursing colleague who speaks the same language as the client to interpret the information
    4. During the analysis phase of the nursing process, a nurse must make clinical judgments based on collected data. Which of the following demonstrates accurate analysis?
      A)The nurse compares the client's vital signs to baseline and refrains from charting deviations
      B)The nurse correlates fever patterns with potential signs of infection
      C)The nurse consults a colleague about the symptoms without reviewing the patient history
      D)The nurse documents the client's reported pain level without further inquiry
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