Exam 2 - NCLEX Questions

During the auscultation of a patient's heart sounds, the nurse asks the patient to turn onto the left side. Why is this position used during the examination?A)Accentuates aortic murmurs B)Accentuates mitral stenosis C)Accentuates the first heart sound D)Accentuates atrial repolarization

B

The client asks the nurse what the small P wave on her ECG indicates. What should the nurse answer? A) Ventricular depolarization B) Atrial depolarization C) Ventricular repolarization D) Atrial repolarization

B

The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than 2 times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain? A) Odynophagia B) Dyspepsia C) Dysphagia D) Discomfort

B

When assessing the posterior chest, what is a starting point for counting ribs and interspaces? A) 10th rib B) 12th rib C) 8th rib D) 6th rib

B

You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly doesn't see your fingers until they have crossed the line of gaze. You would document that the patient has what? A) Bitemporal hemianopsia B) Left temporal hemianopsia C) Quadrantic defect D) Homonymous hemianopsia

B

You note that your patient has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes? A) Patient's vitamin intake B) Patient's hydration status C) Patient's intake of protein D) Patient's BMI

B

What term is used to describe the degree of vascular resistance to ventricular contraction? A) Volume afterload B) Afterload C) Contractile overload D) Preload

B) Afterload

The nurse hears a quiet murmur immediately after placing the stethoscope on the chest. Documentation of grading for this murmur would include A) Grade 1 B) Grade 2 C) Grade 3 D) Grade 4

B) Grade 2

Understanding pressures in the left atrium, left ventricle, and aorta is fundamental to understanding heart sounds. Place the following in order of pressures and sounds through one cardiac cycle A) Mitral valve closes producing S1 B) Aortic pressure is greater than ventricular pressure C) The atrium is empty and pressures in the ventricles increase slightly D) Aortic valve closes producing S2 E) Ventricular pressure increases and forces the opening of the aortic valve F) S3 and S4 may be heard if pathologic ventricular compliance

B, A, C, F, E, D

Over a 24-hour period there is a striking variation in BP levels. What can cause these variations? (Select all that apply) A) Size of meals B) Time of day C) Noise D) Environmental temperature E) Sugar ingestion

B, C, D

The nurse should assess or ask about which associated factors when a patient complains of cluster headaches? Select all that apply A) Photophobia B) Lacrimation C) Miosis D) Rhinorrhea E) Ptosis

B, C, D, E

What are associated manifestations of a headache caused by a traumatic head injury? Select all that apply A) Changes in appetite B) Attention span deficit C) Apathy D) Gait changes E) Seizures

B, D, E

What does the nurse assess the face for? A) Affect B) Asymmetry C) Hair color D) Involuntary movements E) Edema

B, D, E

A patient tells the nurse that he is constantly congested in spite of using a decongestant at least twice daily. The nurse understands the patient may be experiencing A) Allergic rhinitis B) Rhinorrhea C) Rhinitis medicamentosa D) Vasomotor rhinitis

C

During the auscultation of a patient's heart sounds, the nurse hears a fixed S2 split. What does this heart sound indicate to the nurse A) Pulmonic stenosis B) Right bundle branch block C) Right ventricular failure D) Left bundle branch block

C

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A) Superficial to the sternomastoid B) In front of the ear C) In the midline, a few centimeters behind the tip of the mandible D) At the angle of the mandible

C

The nurse is assessing a patient's readiness to quit smoking. Place in order the steps in which the nurse will conduct this assessment. a. Arrange follow-up b. Ask about tobacco use c. Assist to quit d. Advise to quit e. Assess willingness to quit A)b, e, d, c, a B)e, b, d, a, c C)b, d, e, c, a D)a, b, e, d, c E)a, d, e, c, b

C

The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use? A) Tongue blade B) Gloves C) Gauze pad D) Penlight

C

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document? A) Flatness B) Tympany C) Dullness D) Hyperresonance

C

What is a characteristic symptom of Graves hyperthyroidism? A) Pinguecula B) Episcleritis C) Exophthalmos D) Pterygium

C

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination A) To assist the client to feel more comfortable B) To promote further dehydration C) To observe the movement of the thyroid gland D) To promote the nurse-client relationship

C

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: A) Turbinates, ethmoid sinuses, and nasal passages B) Ala nasi, vestibule, and ethmoid sinuses C) Vestibule, nasal passages, and nasopharynx D) Ala nasi, turbinates, and nasopharynx

C

Which area of the heart should be further assessed in the patient with an irregular pulse? A)Right ventricle B) Left ventricle C) Right atrium D) Left atrium

C

You note bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. What would you document? A) Arteriovenous crossings B) Hyperopia C) Papilledema D) Positive axoplasmic sign

C

What do oscillations in the internal jugular veins reflect? A) Changing pressures within the left ventricle B) Changing pressures within the right ventricle C) Changing pressures within the right atrium D) Changing pressures within the left atrium

C) Changing pressures within the right atrium

When assessing a patient with Graves disease, how would you expect the thyroid gland to be? A) Tender B) Nodular C) Soft D) Firm

C) Soft

The nurse in counseling a patient with hypertension. Which recommendations regarding diet should be included in the counseling? Select all that apply A) Dried fruits once a week are OK B) Avoid orange juice C) Decrease foods high in sodium D) Increase foods high in potassium E) Tuna is acceptable as a fish source

C, D

A client is brought to the ED by ambulance after being involved in an MVA. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? A) Atelectasis B) Asthma C) Muscular weakness D) Pneumothorax

D

A female patient presents with right lower quadrant pain that radiates from the periumbilical area. The abdomen is rigid on palpation. The nurse would prepare for physician follow-up for possible A) Diverticulitis B) Peptic ulcer disease C) Small bowel obstruction D) Pelvic inflammatory disease

D

During the health history of the eye, a patient tells the nurse about occasional floaters within the field of vision. The nurse identifies the structure causing this symptom to be from the A) Retina B)Brainstem C)Cerebellum D) Vitreous humor

D

The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for? A) Biliary colic B) Acute diverticulitis C) Acute cholecystitis D) Acute pancreatitis

D

The nurse examines the pharynx of a patient and records that the tonsils are touching the uvula. The nurse would grade the tonsils as A) 1+ B) 4+ C) 2+ D) 3+

D

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order) 1) Over the trachea in the neck 2) Over the manubrium 3) Between the scapulae 4) Over most of the lungs

1) Over most of the lungs 2) Between the scapulae 3) Over the manubrium 4) Over the trachea in the neck

When doing an examination of the thyroid gland, the suggested sequence of examination for a posterior approach is 1) Place the fingers of both hands on either side of the thyroid 2) Flex the neck forward 3) Displace the trachea right then left, evaluating the margins of the lobes 4) Have the patient sip and swallow

4, 1, 2, 3

A patient is diagnosed with an obstruction of the canal of Schlemm. What will the nurse find when assessing this patient's eyes? A) Increased intraocular pressure B) Decreased intraocular pressure C) Displaced optic nerve D) opaque lens

A

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? A) Sound heard throughout inspiration and about 2/3 of expiration B) Inspiratory and expiratory sounds equal in length C) Expiratory sounds lasting longer than inspiratory sounds D) Short silence between inspiration and expiration

A

The nurse is preparing to conduct a physical examination of a patient's abdomen. Identify the area where the nurse will focus the assessment of the patient's gallbladder. A) RUQ B) RLQ C) LUQ D) LLQ

A

What are the glands that are located on the tarsal plates and open on the lid margins? A) Meibomian glands B) Chalazion glands C) Pterygium glands D) Levator glands

A

When evaluating the jugular venous pressure in a patient with known coronary artery disease, the nurse explains to the patient that the JVP measures the pressure in the A) Right atrium B) Left atrium C) Right ventricle D) Left ventricle

A

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point? A) Mobile phones should only be used if a hands-free option is available B) A car seat should only be installed in the front if there are passenger airbag available - depends on your age; most children should be in back seat C) Refrain from taking any medication prior to operating a motor vehicle D) Helmets can obscure vision when riding all-terrain vehicles and should be avoided

A

You are counseling a 44-year-old woman about ways to maintain her weight, which is within normal range for her height. What should you suggest for her? A) 60 minutes per day of physical activity at a moderate intensity B) 45 minutes per day of physical activity at a moderate intensity C) 30 minutes per day of physical activity at a moderate intensity D) 15 minutes per day of physical activity at a moderate intnsity

A

While the nurse is obtaining a client's health history regarding the head and neck, the client reports having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next? A) Do you have difficulty swallowing? B) How long have you experiences discomfort from the lump? C) When did you first notice the lump? D) Is there more than one lump?

A (b/c associated manifestations are effects or other signs and symptoms of the chief complaint (in this case, the lump); difficulty swallowing may indicate an emergency situation)

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? A) Assess the client's blood pressure B) Provide medication for pain relief C) Inquire about history of headaches D) Review the client's medical record

A (what other signs and symptoms do they have? BP should be checked in case it's due to high blood pressure or a brain bleed)

The nurse hears a murmur in a patient with a known mitral valve prolapse. The murmur most likely occurs in A) Late systole B) Mid systole C) Mid diastole D) Early diastole

A) Late systole

When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? A) T4 spinous process B) Midaxillary line C) Sternal angle D) Suprasternal notch

A) T4 spinous process

After a health history of the gastrointestinal and urinary systems, the nurse determines that a patient is of average risk for colorectal cancer. What should the nurse instruct the patient regarding this risk? Select all that apply. A)Have a fecal occult blood test done annually. B) Schedule a flexible sigmoidoscopy every 5 years. C) Follow an every 10-year colonoscopy schedule. D)Plan time for a colonoscopy every 3 years. E)Determine when to have a barium enema every 2 years.

A, B, C

As a nursing student, you learn that obesity-related risk factors include what? Mark all that apply A) Infertility B) Polycystic ovarian syndrome C) Androgenicity D) Type 1 diabetes E) Hypermenorrhea

A, B, C

During the physical examination of the abdomen, the nurse palpates a mass in the patient's right lower quadrant. The nurse suspects that this mass could be associated with which organs? Select all that apply. A)Appendix B) Bladder C)Ascending colon D)Right kidney E) Transverse colon

A, B, C

When assessing for an appendicitis, what signs might the nurse look for? Select all that apply. A) Psoas sign B) Cutaneous hyperesthesia C) Rovsing sign D) Murphy sign E) Obfuscator sign

A, B, C

Which of the following are causes of weight loss? Mark all that apply A) Adrenal insufficiency B) Chronic infections C) Chronic renal failure D) Hypothyroidism E) Chronic heart failure

A, B, C

During a health history of the respiratory system, a patient complains of having a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? Select all that apply. A)Does this occur at a particular time of day? B)Is it continuous or intermittent? C)Does it occur at rest or with exercise? D)Does it wake you at night? E) Do you cough up mucus or phlegm?

A, B, C, D

During the examination of the abdomen, a patient experiences right lower quadrant rebound tenderness. The nurse should do which additional assessment techniques for this patient? Select all that apply. A)Assess the Rovsing sign. B)Assess the psoas sign. C)Test for cutaneous hyperesthesia. D)Look for the obturator sign. E) Test for a fluid Wave.

A, B, C, D

The nurse wants to include a patient's lifestyle habits when conducting the health history of the eye. What will the nurse include in this assessment? Select all that apply. A)Smoking history B)Use of sunglasses C)Use of protective eyewear D)Current medications that dry the eye E)Use of corrective eyeglasses or contact lenses

A, B, C, D

A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply A) Constipation B) Cool skin C) Lethargy D) Weight loss E) Lower systolic BP

A, B, C, E

The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply) A) Examining the face B) Inspecting and palpating the precordium C) Examining the neck D) Auscultating the lungs E) Inspecting the hands and lower legs

A, B, C, E

The nurse notes guarding while palpating the abdomen of a newly admitted patient despite asking the patient to try to relax. The nurse should (select all that apply) A) Have the patient mouth breathe while the jaw dropped open B) Assess relaxation of abdominal muscle after the patient exhales C) Have the patient stand during the examination D) Distract the patient with conversation E) Tell the patient to take a deep breath and hold it

A, B, D

Your patient is complaining of nasal stuffiness. What drugs should you ask if she is taking? Mark all that apply A) Guanethidine B) Oral contraceptives C) Nicotine D) Alcohol E) Guaifenesin

A, B, D

The nurse is preparing to conduct a physical examination of a patient's cardiovascular system. What should the nurse instruct the patient in preparation for this examination? Select all that apply. A)Wear the gown with the opening in the front. B)A sheet will be draped over the patient for comfort. C)The patient will be standing during the examination. D) Explain that gloves will be worn during the examination. E)The nurse will be conducting the examination from the left side.

A, B, D, E

A patient has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. A) Blood pressure B) Cholesterol C) Medications D) Temperature E) Activity level

A, B, E

A patient is diagnosed with coronary heart disease and hypertension. What can the nurse instruct this patient to help reduce the modifiable risk factors for both of these disorders? Select all that apply. A) Importance of weight reduction B)The need to increase physical activity C)Reducing alcohol consumption D) Having kidney function checked each year E)Way smoking cessation is necessary

A, B, E

What associated symptoms might a patient with a history of chronic bronchitis have? Mark all that apply A) Wheezing B) Recurrent respiratory infections C) Orthopnea D) Paroxysmal nocturnal dyspnea E) Chronic productive cough

A, B, E

What are the bordering landmarks of the anterior triangle of the neck? A) The midline of the neck B) The clavicle C) The mandible D) The sternomastoid E) The omohyoid muscle

A, C, D

What can cause bladder distention? Mark all that apply. A) Multiple sclerosis B) Rectal abscess C) Stroke D) Perineal fissure E) Medications

A, C, E

The nurse is admitting a client who is in hypertensive crisis. The doctor's notes indicate that bruits that are both systolic and diastolic have been noted and renal artery stenosis is suspected as the cause of the hypertension. Where would the nurse auscultate the patient's abdomen to hear these bruits? Select all that apply A) RUQ B) Iliac arteries C) Femoral arteries D) Epigastrium E) Costovertebral angles

A, D, E

What systemic diseases may cause nodular episcleritis? Mark all that apply A) Rheumatoid arthritis B) Fibromyalgia C) Multiple sclerosis D) Muscular dystrophy E) Systemic lupus erythematosus

A, E

A 55-year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses are consistent with her gesture? A) Costochrondritis B) Anging pectoris C) Bronchitis D) Pericarditis

B

A patient asks the nurse why the neck veins need to be checked when the patient is experiencing heart palpitations. What should the nurse respond to this patient? A)"They detect the function of the aortic valve B) "They help determine how much pressure is in the right atrium of the heart" C) "They are used to detect the heart rate D) "They are used to estimate blood pressure.

B

During a physical assessment of the abdomen, the nurse palpates a small mass above a patient's symphysis pubis. What should the nurse do at this time? A)Gently press down on the mass. B) Stop the examination. C) Auscultate the mass. D)Percuss the mass.

B

A client arrives in the ED by ambulance after falling down his front steps. The nurse notes 2 soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as? A) Pigmented nevi B) Edema from fall C) Pilar cysts D) Signs of abuse

C

A patient has COPD. On examination, the nurse would expect A) The liver to be enlarged B) Difficulty in percussing liver dullness C) Liver dullness to be displaced downward D) The liver span to be decreased

C

A patient in the clinic where you work is considered legally blind. The nurse knows that this means that the vision in his better eye, corrected by glasses, is what? A) 20/300 or less B) 20/400 or less C) 20/100 or less D) 20/200 or less

C

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment? A)Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. B)Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. C)Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver. D)Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

D

The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse? A)Healthy lung tissue B)Gastric air bubble C) Chronic bronchitis D) Pleural effusion

D

What structure in the inner ear senses the position and movements of the head and helps to maintain balance? A) The ossicle B) The cochlea C) The umbo D) The labyrinth

D

When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse? A) The lung is full of fluid B) The lung is overinflated C) The lung has an embolus D) The lung has become airless

D

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? A) Left lower B) Left upper C) Right lower D) Right upper

D

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems? A) Rhinorrhea B) Fever C) Headache D) Vertigo

D (dizziness, imbalance)

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? A) Painful breathing B) Audible breathing C) Prolonged inspiration D) Air hunger

D) Air hunger

The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents A) Exophthalmos B) Ptosis C) Ectropion D) Entropion

D) Entropion

What should the nurse include when documenting the physical examination of a patient's eyes? Select all that apply. A)Presence of double vision B)Trauma to the eye C)Diagnosis of diabetes D)Shape and sizeof the pupils E)Appearance of the optic disc

D, E

T/F A patient with lobar pneumonia would have muffled and indistinct spoken voice sounds

F

To function adequately, the nurse knows that the heart valves need to open simultaneously T/F

F

T/F It has become apparent that there is not a lifetime immunity to pertussis for those who received the childhood DPT vaccine

T

T/F Lung tissue has no pain fibers

T

T/F The nurse might expect the patient admitted with dehydration to have tachycardia

T

T/F The thyroid gland is usually larger in women than in men

T

The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space. True False

True