Exam 1 - Missed NCLEX Review Questions

T/F Walking contracts the calf muscles and forces blood away from the heart

False

True/False The radial pulse is palpated over the lateral flexor surface

False

_____ is a mnemonic that can help the nurse ask specific questions when performing an assessment, while _____ is a mnemonic that can help the nurse remember the steps in the nursing process

OLD CART; ADPIE

The new RN is now performing the examination of the abdomen. What order of examination techniques would be correct? 1) Palpation 2) Auscultation 3) Inspection 4) Percussion

1) Inspection 2) Auscultation 3) Percussion 4) Palpation *Note this is just the order for the abdomen because percussion increases bowel motility and alter the sounds heard on auscultation. The usual order is inspection, palpation, percussion, and auscultation*

How does a nurse best facilitate the nursing health assessment? A) Creating a nursing care plan B) Formulating a nursing diagnosis C) Asking the appropriate questions D) Maintaining privacy

B) Formulating a nursing diagnosis

What mechanisms produce edema? Select all that apply A) Hyperglycemia B) Increased capillary blood pressure C) Low plasma protein levels D) Arterial insufficiency E) Capillary leak system

B) Increased capillary blood pressure C) Low plasma protein levels E) Capillary leak system

Fatigue is considered a common symptom of what? (Mark all that apply.) A) Hyperthyroidism B) Infections C) Mild anemia D) Panhypopituitarism E) Depression

B) Infections D) Panhypopituitarism E) Depression

The nurse is assessing a patient with Raynaud disease. When assessing the wrist pulses, what would the nurse expect to find? A) Bounding wrist pulses B) Normal wrist pulses C) Absent wrist pulses D) Decreased wrist pulses

B) Normal wrist pulses

You are attending a seminar on transcultural nursing at a nursing conference. What aspects of culture relevant to health assessment would you expect to be discussed? Mark all that apply. A) Educational goals B) Nutrition C) Health care practitioners D) High-risk behaviors E) Wound care

B) Nutrition C) Health care practitioners D) High-risk behaviors

Mr. Smith presents to the clinic stating, "my face looks funny." You note that his face is asymmetric. What might you suspect is the patient's problem? A) Myocardial infarction B) Palsy C) Parafacial macrosomia D) Muscular dystrophy

B) Palsy

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal findings should the nurse classify as objective data? A) Worries about appearance B) Reports of hair loss C) Anxious appearance D) Itching sensation all over the body

C) Anxious appearance

In diagnosing a bigeminal pulse, the nurse would expect (select all that apply) A) Increased peripheral resistance B) Premature contraction C) Aortic regurgitation D) Diminished SV E) Normal beat

Premature contraction Diminished SV Normal beat

When performing a physical examination, the nurse should examine the body in which order? 1) Heart murmur 2) Groin 3) Gait 4) Tongue movement 5) CVA tenderness 6) Thyroid

1) Tongue movement 2) Thyroid 3) Heart murmur 4) CVA tenderness 5) Groin 6) Gait

The vaso vasorum is found where? A) Adventitia of the artery B) Venous intima C) Inferior vena cava D) Superior vena cava

A) Adventitia of the artery

When listening to a lecture, the students learn that there are three dimensions of cultural humility, which include (select all that apply) A) Collaborative partnerships B) Religious structures C) Self-awareness D) Respectful communication

A) Collaborative partnerships C) Self-awareness D) Respectful communication

A patient describes a tight pain in the tibial area of his leg. Upon inspection, the nurse notes dusky, red skin. The suspected diagnosis would be A) Compartment syndrome B) Intermittent claudication C) Acute lymphangitis D) Raynaud disease

A) Compartment syndrome

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? A) Do you have family who visit you regularly? B) Have you tried to schedule a cleaning service? C) What amount of cleaning have you been doing in the past? D) Are you friendly with your neighbors?

A) Do you have family who visit you regularly?

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process? A) Emotional B) Spiritual C) Social D) Mental

A) Emotional

What general goals do you organize your comprehensive or focused examination around? Select all that apply. A) Enhancing clinical efficiency B) Maximizing the patient's comfort C) Identifying the patient's medical diagnosis D) Avoiding unnecessary changes in position E) Ensuring the patient's compliance with treatment

A) Enhancing clinical efficiency B) Maximizing the patient's comfort D) Avoiding unnecessary changes in position

Equipment used in conducting a physical examination includes a 2x2 gauze pad. What is this used for? A) Examining the tongue B) Testing facial sensation C) Invoking the blink reflex D) Inverting the eyelid

A) Examining the tongue

When culture is defined as a system, what components would be included? Mark all that apply. A) How we view the world B) Shared ideas, rules, and meanings C) Cognitive ability of the patient D) How we experience the world physically E) How we behave in relation to other people

A) How we view the world B) Shared ideas, rules, and meanings E) How we behave in relation to other people

The client has a difference between the highest and lowest systolic pressure of 12 mm Hg. What does this indicate? Select all that apply A) Obstructive airway disease B) Pericardial tamponade C) Possibly constrictive pericarditis D) Complex atheroma E) Peripheral arterial disease

A) Obstructive airway disease B) Pericardial tamponade C) Possibly constrictive pericarditis

The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a A) Papule B) Wheal C) Bulla D) Pustule

A) Papule

What is a function of the lymph system? A) Produce antibodies B) Drain lymph fluid from the vascular bed C) Transport nutrients to the tissues D) Clean the blood

A) Produce antibodies

You have finished the physical examination. What do you do immediately after finishing? (Mark all the apply) A) Tell patient what to expect next B) Give your general impressions C) Share findings with physician D) Perform interventions E) Identify needed lab tests

A) Tell patient what to expect next B) Give your general impressions

The nurse reads the previous shift's assessment documentation and notes local swelling, redness, and warmth. The oncoming nurse palpates a subcutaneous cord and suspects A) Venous insufficiency B) A superficial thrombophlebitis C) Femoral aneurysm D) DVT

B) A superficial thrombophlebitis

The "evil eye" is an example of what? A) A psychosocial condition B) An ethnic belief C) A cultural-bound syndrome D) A spiritually defined illness

B) An ethnic belief

The nursing instructor is discussing the great and small saphenous veins. What would the instructor say connects these two veins? A) Anastomotic veins B) Communicating veins C) Bridging veins D) High-pressure veins

B) Communicating veins

When planning a community program related to Healthy People 2020, the critical first step involves A) Planning an introductory program for the community B) Defining the community C) Assessing the community D) Formulating questions to ask community leaders

B) Defining the community

The apocrine glands are stimulated by what? A) Overhydration B) Emotional stress C) Physical stress D) Temperature

B) Emotional stress

When studying Campinha-Bacote's model of cultural competency in the delivery of health care, you learn that cultural desire is viewed as the motivation for the nurse to want to do what? Mark all that apply. A) Seek cultural compassion B) Seek cultural encounters C) Become culturally skillful D) Become ethnically expert E) Become culturally knowledgeable

B) Seek cultural encounters C) Become culturally skillful E) Become culturally knowledgeable

The ulnar edge of the hand if is highly receptive to which of the following sensations? A) Moisture and contour B) Temperature and vibrations C) Contour and temperature D) Vibrations and moisture

B) Temperature and vibrations

When performing a cultural assessment, an important point to remember would be A) that alternative therapies are reasons for seeking care B) that definitions of family differ C) to use first names of those you are speaking to D) that the cultural/ethnic background is evident in the patient's appearance

B) that definitions of family differ

To adhere to standard precautions, the nurse should remember to (select all that apply) A) Wear gloves with each patient contact B) Put on a cover gown when entering a patient's room C) Change white coat frequently D) Wash hands before and after patient contact

C) Change white coat frequently D) Wash hands before and after patient contact

The nurse should know that some disease processes affect the facial expression. What are they? Mark all that apply. A) Diabetes mellitus B) Multiple sclerosis C) Depression D) Parkinsonism E) Hyperthyroidism

C) Depression D) Parkinsonism E) Hyperthyroidism

When utilizing the website www.healthypeople.gov, the nurse notes completing of the first 2 areas in the acronym MAP-IT while working on a project for a Hispanic community within a large city. What action by the nurse would fulfill the next step in this process? A) Planning a community kick-off event at the school gym B) Evaluating what changes are needed before the next event C) Developing a goal for the community involved D) Facilitating input by scheduling a community meeting

C) Developing a goal for the community involved

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? A) Saphenous B) Communicating C) Popliteal D) Iliofemoral

C) Popliteal

Which of the following are part of the preinterview of the nurse-patient interview? Select all that apply A) Establishing the agenda B) Identifying the patient's emotional cues C) Taking time for reflection D) Generating diagnostic hypotheses E) Setting goals for the interview F) Taking notes

C) Taking time for reflection E) Setting goals for the interview F) Taking notes

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the school nurse suspect? A) Addison disease B) Tinea versicolor C) Vitiligo D) Dermatomyositis

C) Vitiligo

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed A) Entry B) Exploratory C) Focused D) Comprehensive

D) Comprehensive

Remember that in a genogram, females are represented by _____ and males are represented by _____

Circles; squares

A nurse documents periods of deep breathing followed by period of apnea. The appropriate term for this type of breathing is A) Hypopnea B) Obstructive C) Ataxic D) Cheyne-Stokes

D) Cheyne-Stokes

When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the patient about alcohol use. The question most appropriate to ask next would be: A) Do you take illegal drugs? B) Tell me why you drink so much C) Is there a family history of alcohol abuse? D) Do you ever drink then drive?

D) Do you ever drink then drive?

When assessing your new patient, you note that he has not hair on his legs. What might this indicate about the patient? A) He has a hormonal imbalance B) He has hyperthyroidism C) He has hypothyroidism D) He has peripheral artery disease

D) He has peripheral artery disease

The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the patient? A) Allen test B) Venous occlusion test C) Ankle-brachial index test D) Trendelenburg test

D) Trendelenburg test

The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action? A) Perform a bladder scan B) Collect a urinalysis C) Apply suprapubic pressure D) Verify positioning of the catheter

D) Verify positioning of the catheter

Remember that when using the bell of the stethoscope, you will be able to hear (higher/lower)-pitched sounds

Lower

T/F A patient with a subdural hematoma may have an odor of alcohol

True

T/F Local redness of the skin warns of impending necrosis

True

T/F The meaning of ethnicity is broader than the term culture

True