Nursing 251 Quizzes

While performing transillumination over the frontal sinuses, the nurse discovers a red glow. What does this finding represent? a. An expected finding b. Inflammation c. Infection d. Fluid-filled sinus cavity

A

Which type of question would be the most effective in obtaining a patient's perceptions of his or her problem? a. Open-ended questions b. Close-ended questions c. Leading questions d.Accusing questions

A

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to a. repeat the phrase "ninety-nine" b. repeat the letter "E" c. whisper the phrase "one-two-three" d. repeat the letter "A"

A

While caring for an 80 year-old client in his home, the nurse determines that the client's temperature is 96.5 degrees F. The nurse determines that the client is most likely exhibiting a. normal changes that occur with the aging process b. hypothermia that occurs before an infectious process c. a metabolic disorder resulting in circulatory changes d. an immune disorder resulting in low platelet count

A

When palpating for the apical pulse of a patient, where should the "normal" location be? a. 6th ICS, MAL b. 5th ICS, MCL c. 3rd ICS, just left of the midsternal line d. 2nd ICS, left of the sternum

B

When performing an otoscopic exam on an adult patient of the right ear, Where would the nurse document seeing the cone of light if it was in the appropriate place? a. In the center of the tympanic membrane b. In the 5 O'clock position c. In the 7 O'clock position d. In the upper left quadrant

B

Which area of the breast is breast cancer the most prevalent? a. Upper inner quadrant b. Upper outer quadrant c. Lower inner quadrant d. Lower outer quadrant

B

Which of the following signs is indicative of meningitis? a. Doll's eyes b. Nuchal rigidity c. Babinski d. Tinel

B

While assessing an adults client's jaw, the nurse hears a clicking popping sound, and the client expresses pain in the joint. The nurse should further assess the client for a. arthritis b. TMJ dysfunction c. bruxism d. previous fracture

B

Match the following types of skin cancer with the appropriate statements below; may use the types more than once: 1. Usually evaluated by the mnemonic ABCDE 2. Most common skin cancer in caucasions 3. Most serious type and most rapidly increasing cancer in the U.S. 4. Most common skin cancer in darker skinned individuals 5. Associated with overall sun exposure and common on body sites with heavy sun exposure 6. Common on body sites with moderate sun exposure a. basal cell Carcinoma b. Malignant Melanoma c. Squamous cell Carcinoma

1. Malignant 2. basal cell 3. malignant 4. squamous cell 5. squamous cell 6. basal cell

A patient has a blood pressure reading of 130/90 mmHg when visiting a clinic. What would the nurse recommend for this patient? a. Follow-up measurements of blood pressure b. Immediate treatment by a primary care provider c. Nothing, because the nurse considers the reading due to the patient's anxiety d. A change in diet and exercise

A

A patient has experienced a stroke and now has +3/5 strength of the upper extremities on the right side and +5/5 strength on the left side. Which term is used to define this right-sided weakness? a. Hemiparesis b. Hemiplegia c. Hemiparalysis d. Hemicolectomy

A

Match the following to the condition below. Normal/ Abnormal 1. Crackles in the bases bilaterally 2. E to A changes noted with egophony 3. Respiratory expansion of 5-10 cm in an adult patient 4. AP:LAT chest diameter = 1:1 5. Equal fremitus bilaterally with palpation 6. Bluish-tinged lips and fingernail beds 7. Nasal flaring in an infant patient

1. abnormal 2. abnormal 3. normal 4. abnormal 5. normal 6. abnormal 7. abnormal

State which of the following are Normal or Abnormal finding: 1. Bulging tympanic membrane 2. No lateralization, sound heard in both ears, with Weber test 3. AC = BC with Rinne test 4. Tips of pinna slightly above canthus line of eyes

1. abnormal 2. normal 3. abnormal 4. normal

Define the following as NORMAL or ABNORMAL: 1. Tongue deviates involuntarily to right 2. Mucous membranes pink, moist 3. Absent bowel sounds in a surgical client immediately post-operatively 4. Slight nystagmus noted at far lateral movements of cardinal fields 5. Pupils equal, round, react sluggishly to light

1. abnormal 2. normal 3. normal 4. normal 5. abnormal

Match the following with the proper condition 1. Rheumatoid arthritis 2. scoliosis 3. carpal tunnel syndrome 4. lordosis 5. kyphosis a. S- curve to spine b. hump back c. swan neck deformity on fingers d. tinel sign e. sway back

1. c 2. a 3. d 4. e 5. b

Match the terms below with the correct definitions 1. assessment 2. nursing diagnosis 3. planning 4. implementation 5. evaluation a. clinical judgement about individual, family, or community responses to actual or potential health problems and life processes b. assessing whether outcome criteria have been met and revising the plan of care if necessary c. collection of subjective and objective data d. developing a plan of nursing care and outcome criteria e. carrying out the plan

1. c 2. a 3. d 4. e. 5. b

Match the interviewing technique to the respective definition 1. Establishing rapport with the patient by identifying feelings of the patient 2. Identifying and stating observations that seem to be at odds with statements, behavior, etc. 3. Repeating the patient's own words to encourage expression of facts and feelings. 4. An inference about feelings or concerns that is used to clarify data already collected. 5. Cueing a patient to continue by saying "mm-mm, using silence, etc. a. reflection b. confrontation c. empathetic responses d. interpretation e. facilitation

1. c 2. b 3. a 4. d 5. e

Match the following terms with the appropriate definition below: 1. Double vision 2. Uncoordinated eyes, crossed eyes 3. Drooping eyelid 4. Vision loss with aging 5. Farsightedness 6. Lazy eye, dimness of vision a. ptosis b. hyperopia c. diplopia d. amblyopia e. strabismus f. presbyopia

1. c 2. e 3. a 4. f 5. b 6. d

Match the Cranial Nerve with the Correct Function of the nerve 1. Visual impulses from the eye to the brain 2. Sensory impulses for hearing and balance 3. Pupil constriction 4. Smell impulses from the nose to the brain a. CN 8 b. CN 1 c. CN 2 d. CN 3

1. c 2. a 3. d 4. b

Match the lesion below to the appropriate cause: 1. Measles 2. Chicken pox (varicella) 3. Burns 4. Venous stasis/arterial insufficiency 5. Mosquito bite a. ulcers b. wheal c. red-maculo-papilar rash d. vesicle e. bullae

1. c 2. d 3. e 4. a 5. b

Match the following Cranial Nerves with their function and/or testing technique: 1. Uvula rises bilaterally with phonation 2. Shrug shoulders against resistance 3. Tongue midline 4. Sense of sharp/dull on face a. CN 5 b. CN 12 c. CN 10 d. CN 7 e. CN 11

1. c 2. e 3. b 4. a CN 7 not used

Match the following tests to intellectual functioning to the correct usage of the test 1. How many quarters are in $1.75? 2. Remember this sentence and then repeat it to me a few minutes later. 3. Ask questions about presidents, names of oceans,or current events. 4. What would you do if you were in a movie theater and a fire broke out? 5. What does "A rolling stone gathers no moss" mean to you? a. comprehension b. judgement c. abstraction d. computation e. general knowledge

1. d 2. a 3. e 4. b 5. c

Match the following terms with the correct definition. 1. May be an early sign of heart failure in an older adult patient 2. Located in the 5th ICS, MCL 3. Corresponds with the carotid pulse 4. Located in the 2nd ICS, right of the sternum 5. Located in the 3rd ICS, just left of the sternum 6. Located in the 2nd ICS, left of the sternum 7. Located in the 5th ICS, left of the sternum 8. Caused by the closure of the semilunar valves a. Erb's point b. tricuspid area c. mitral area d. S3 e. S2 f. Aortic Area g. pulmonic area h. S1

1. d 2. c 3. h 4. f 5. a 6. g 7. b 8. e

Match the following tests with the appropriate method of testing 1. Touch skin on same areas on both sides of body 2. Touch client simultaneously with 2 points; note if feels one or two points 3. "Write" letter of number in client's palm; Client identifies 4. Move client's great toe back and forth 5. Place familiar object in hand (coin, paper clip, etc) and patient identifies a. proprioception b. graphesthesia c. stereognosis d. extinction e. two-point discrimination

1. d 2. e 3. b 4. a 5. c

Match the type of pain with the definition. 1. diffuse, hard to locate, originates from organs 2. pain in an area removed from the tissue causing the pain 3. diffuse, originates in muscles, joints or parietal surfaces 4. pain which moves outward from a central location a. referred b. cutaneous c. deep somatic d. radiating e. visceral

1. e 2. a 3. c 4. d not used: cutaneous

Match the following types of skin lesions with the appropriate definition below: 1. Fluid-filled, circumscribed, elevated, greater than 0.5 cm 2. Circumscribed, non-elevated, non-palpable, less than 1 cm 3. Palpable elevated solid mass, 0.5 to 1 - 2 cm 4. Palpable elevated solid mass, a wart 5. Palpable elevated solid mass, greater than 1-2 cm 6. Circumscribed, non-elevated, non-palpable, greater than 1 cm a. macula b. tumor c. patch d. nodule e. bulla f. papule

1. e 2. a 3. d 4. f 5. b 6. c

What test do you use to test a client's peripheral vision? A. Cover/uncover test B. Confrontation C. Cardinal fields of vision D. Snellen test

B

Match the signs below to the possible condition they represent. 1. Rebound tenderness when RLQ palpated; appendicitis 2.Abdominal pain radiating to left shoulder; spleen 3. Abrupt stopping of breathing when palpating RUQ; gallbladder 4. Ecchymosis of flanks; internal bleeding 5. Ecchymosis around umbilicus; internal bleeding a. Murphy's signs b. kehr's sign c. Grey- Turner's sign d. cullen's sign e. McBurney's sign

1. e 2. b 3. a 4. c 5. d

Match the parts of the brain with correct function 1. visual cortex 2. wakefulness 3. balance and coordination 4. proprioception and sensory input 5. personality, judgement, and level of conciousness 6. hearing and short term memory a. brain stem b. frontal lobe c. temporal lobe d. parietal lobe e. cerebellum f. occipital lobe

1. f 2. a 3. e 4. d 5. b 6. c

Match the following terms to the correct definition 1. turn up 2. outward 3. moving toward midline 4. inward 5. moving away from midline 6. paralysis on one side of the body 7. turning to right of left 8. turn down a. adduction b. rotation c. pronation d. eversion e. abduction f. inversion g. hemiplegia h. supination

1. h 2. d 3. a 4. f 5. e 6.g 7. b 8. c

Match the following terms with the correct description or definition. 1. High-pitched, short, popping sounds on inspiration 2. Forward protusion of the sternum 3. High-pitched musical sounds 4. Cessation of breathing 5. Irregular breathing with periods of no breathing 6. Low-pitched, continuous snoring soundds 7. Difficulty breathing when lying supine 8. Sudden shortness of breath while sleeping 9. Low-pitched, dry, grating sounds 10. A "crackling" sensation when palpating a. wheezes (sibilant) b. rhonchi (sonorous) c. orthopnea d. pectus carinatum e. Cheyne-Stokes breathing f. apnea g. paroxysmal nocturnal dyspnea h. crepitus i. crackles j. pleural friction rub

1. i 2. d 3. a 4. f 5. e 6. b 7. c 8. g 9. j 10. h

Match the terms below with the correct descriptions 1. normal diastolic BP range 2. diastolic blood pressure 3. normal oral temp 4. normal systolic BP range 5. normal resp rate 6. normal pulse 7. systolic blood pressure 8. pulse pressure 9. overall impression 10. 5th vital sign a. less than 120 mmHg b. highest pressure exerted on the artery walls c. skin color, hygiene, posture, gait, physical build, and development d. difference between systolic and diastolic pressure e. 36.6 degrees C to 37 degrees C (96.0 degrees F to 99.9 degrees F) f. 12 to 20 per min g. 60 to 100 beats per min h. pain i. lowest pressure exerted on the artery walls j. less than 80 mmHg

1. j 2. i 3. e 4. a 5. f 6. g 7. b 8. d 9. c 10. h

Determine which of the following findings are Normal or Abnormal 1. Warm, pink right foot with pedal pulse of +2 2. PMI located at the 6th ICS, AAL 3. Muffled, indistinct S1 and S2 auscultated 4. Pedal pulses +1 bilaterally in a diabetic patient 5. Swishing sound auscultated between S1 and S2 6. Left carotid bruit auscultated in an adult patient 7. Heave noted and thrill palpated in an adult male patient's anterior thorax 8. Absence of lower extremity pitting edema bilaterally in a patient with heart failure 9. Rubor on dependency, shiny, hairless skin of the lower legs bilaterally

1. normal 2. abnormal 3. abnormal 4. abnormal 5. abnormal 6. abnormal 7. abnormal 8. normal 9. abnormal

Determine if the following findings are normal or abnormal: 1. Buccal mucosa pink and moist 2. Lips cracked and dry 3. Head large, thickened bone structure 4. Submental lymph gland soft, nontender 5. Nasolabial folds asymmetrical 6. Thyroid gland hard and nodular 7. Soft palate fused at midline and symmetrical 8. Nasal septum deviated to right

1. normal 2. abnormal 3. abnormal 4. normal 5. abnormal 6. abnormal 7. normal 8. abnormal

Match the following signs and symptoms to the appropriate type of data/ Objective/Subjective 1. warm and dry skin 2. respiration's of 16 breaths per minute 3. pain rated 9 out of 10 4. a complaint of feeling bloated 5. scattered freckles across face of cheeks

1. objective 2. objective 3. subjective 4. subjective 5. objective

Match the section of the exam when putting-it-all-together with the assessment that would be best integrated there: 1. Turgor, elasticity on arms and legs 2. Anterior-posterior diameter 3. Appearance, affect, and hygiene 4. Gait, ability to sit and stand 5. Occitpital, and cervical lymph nodes

1. skin 2. thorax 3. general survey 4. musculoskeletal 5. head and neck

A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of a. Rheumatoid arthritis b. Osteoporosis c. Carpal tunnel syndrome d. Osteoarthritis

A

A family history for a patient with joint pain should include information about which of the following conditions? a. Autoimmune disorders b. Chronic dermatitis c. Chronic obstructive pulmonary disease (COPD) d. Obesity

A

A home health nurse is beginning the physical assessment of a new patient at their home. What is the first piece of information the nurse should obtain? a. Vital signs b. Ability to do activities of daily living c. Height and weight d. Skin color and texture

A

A nurse is examining a new patient admitted to the hospital unit from home. The patient is bed-ridden and transfers to a chair only with the assist of family members. The nurse notes an area of redness that does not blanch with palpation on the patient's buttocks; however, the area's skin is intact. What stage of pressure ulcer development does the nurse document? a. Stage I b. Stage II c. Stage III d. Stage IV

A

A patient complains of severe abdominal pain. When assessing the vital signs of this patient, which of the following would be an expected finding? a. An increase in the pulse rate b. A decrease in pulse rate c. A decrease in blood pressure d. An increase in temperature

A

Because the nurse realizes that spirituality varies, how will the information gained during a spirituality assessment assist the nurse? a. By individualizing interventions to meet specific needs b. In diagnosing the patient with spiritual distress c. In teaching the patient strict adherence to rituals and practices to improve outcomes d. By providing an overview of widely held beliefs from the major religions

A

During a head to toe assessment of a patient the nurse discovers a vascular ulcer at the distal right great toe. This is most likely caused by which of the following conditions? a. Arterial insufficiency b. Venous insufficiency c. Inadequate nutrition d. Friction due to tight shoes

A

George is a 50 year old male that has never sought preventative care prior to today. He arrives at a primary care clinic for the first time. The Registered Nurse (RN) will perform what type of assessment upon meeting George? a. initial/comprehensive b. ongoing/partial c. focused/problem d. emergency

A

How is Acute pain different from Chronic pain? a. Acute pain is often associated with tissue damage and lasts less than 6 months in duration b. Acute pain usually does not need to be treated but chronic pain is referred for treatment c. Chronic pain is associated with aging and is seen usually in persons over 50 years of age d. Chronic pain is usually visceral in nature and acute pain is mostly cutaneous pain

A

How might an examiner be able to help a patient who seems uncomfortable with close contact during an examination? a. Acknowledge the discomfort b. Back away from the client c. Joke about the client's discomfort d. Move quickly to completion of the exam

A

Shining a light into one eye and noting the pupillary response in the other eye is testing for which of the following parameters? a. Consensual reaction b. Accommodation c. Convergence d. PERRL

A

The cerebrum is divided into right and left hemispheres, which are joined together by the . . . a. corpus callosum b. diencephalon c. medulla oblongata d. pons

A

The findings of a patient's head assessment are as follows: Symmetrical, round, and appropriate for body size. How will the nurse document this finding? a. Normocephalic b. Hydrocephalic c. Abnormocephalic d. Acephalic

A

The nurse asesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent which potential problem? a. A reduction of the blood supply to the brain b. A rapid rise in the client's pulse rate c. A premature ventricular heart sound d. A decreased pulse pressure

A

The nurse is beginning a health history interview with an adult patient who expresses anger at the nurse. What is the best approach by the nurse for dealing with an angry patient? a. Allow the patient to ventilate his/her feelings b. Offer reasons why the patient should not feel angry c. Provide structure during the interview d. Refer the patient to a different health care provider

A

The nurse is performing passive range of motion (PROM) on a patient. Which of the following statements is incorrect? a. The nurse should start PROM at the neck and work head to toe b. The nurse should discontinue PROM on a patient if the patient complains of pain c. The nurse should discontinue PROM on an area if the patient grimaces d. The nurse should finish PROM with the ankles and feet

A

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should . . . a. ask the client to empty his bladder b. place the client in a side-lying position c. ask the client to hold his breath for a few seconds d. tell the client to raise his arms above his head

A

The nurse is preparing to examine an adult client's eyes, using the Snellen chart. What should the nurse do first? a. Position the client 20 feet away from the chart b. Ask the client to remove his glasses c. Ask the client to read each line with both eyes open d. Instruct the client to begin reading from the bottom of the chart

A

The opening of the parotid glands is called which of the following? a. Stenson's duct b. Wharton's duct c. Sublingual duct d. Donald duct

A

To percuss the upper border of the liver of an adult client, where should the nurse begin the assessment? At the client's . . . a. Right MCL, 5th ICS b. Right MCL, below umbilicus c. Left MCL, 5th ICS d. Left MCL, below umbilicus

A

What constitutes the manubriosternal (sternal) angle? a. The articulation of the manubrium and the body of the sternum b. The hollow U-shaped depression at the top of the sternum c. The angle formed by the ribs at the lower end of the sternum d. The angle formed by the ribs and the vertebra

A

What constitutes the manubriosternal (sternal) angle? A. The articulation of the manubrium and the body of the sternum B. The hollow U-shaped depression at the top of the sternum C. The angle formed by the ribs at the lower end of the sternum D. The angle formed by the ribs and the vertebra

A

What is the term (when defined broadly) that describes a body of shared traits, art, or ideas? a. Culture b. Customs c. Rituals d. Values

A

Which of the following elicits a peripheral response to pain? a. Nail bed pressure b. Sternal rub c. Trapezius squeeze d. Supraorbital pressure

A

Which of the following represents the correct sequence of spatial relationships for the client to do when testing for accommodation? a. Focus distant to near b. Focus near to distant c. Focus straight ahead and then laterally d. focus laterally to center

A

Which one of the following actions would best promote accurate translations and confidentialityfor the patient when the caregiver does not speak the patient's language? a. Ask a hospital employee unfamiliar with the client to translate b. Ask a friend of the client to translate c. Ask a family member to translate d. Ask the client's neighbor to translate

A

Which one of the following is a risk factor for breast cancer? a. Consuming 2 or more drinks of Alcohol per day b. Beginning menopause at 45 years of age c. Male gender d. Having 2 children before age 30

A

A nurse is preparing to auscultate and percuss a patient's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that may apply a. Tympany b. High-pitched gurgles c. Borborygmi d. Friction rubs e. Bruits

A, B

Which of the following are behaviors of active listening? Select all that may apply. a. Maintaining an open posture b. Writing down what the patient says so that details are not forgotten c. Establishing and maintaining eye contact d. Nodding in agreement with whatever the patient says throughout the conversation e. Responding positively when giving feedback

A, C, E

A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? Select all that may apply. a. Poor wound healing b. Dry brittle hair c. Blood pressure 130/80 mmHg d. Weak hand grips e. Impaired coordination

A,B, D,E

A 16 year old female is referred to the school nurse for a vision test after the teacher notes her squinting to see the front blackboard. The nurse uses which one of the following tools to assess the patient's vision? a. Snellen E chart b. Snellen eye chart c. Ishihara chart d. Allen vision test

B

A blood pressure of 120/80 mmHg is recorded by the nurse. What does the 120 represent? a. Pulse rate b. Systolic pressure c. Diastolic pressure d. Pulse pressure

B

A client who is paralyzed on one side of the body due to a stroke is described by which one of the following terms? A. Paraplegia B. Hemiplegia C. Hemiparesis D. Quadraplegia

B

A female client visits the clinic and complains to the nurse that her skin feels "dry". The nurse should instruct the client that skin elasticity is related to adequate . . . a. Calcium b. Fluid intake c. Vitamin D d. Carbohydrates

B

A hard, enlarged and nontender supraclavicular lymph node may be an indication of which of the following conditions? a. Brain tumor b. Breast Cancer c. Tonsillitis d. Sinusitis

B

Which assessment takes priority in an emergency assessment of a patient? a. Pulse b. Blood pressure c. Airway/breathing d. Skin color

C

A nurse is having difficulty separating the first heart sound, S1, from other adventitious sounds while auscultating a patient's heart sounds. What can the nurse do to assist in determining S1? a. Have the patient take a deep breath and hold it b. Palpate the carotid pulse while listening for S1 c. Have the patient lean to the left d. Doppler the heart sounds to separate S1 from other sounds

B

A simplified, generally inflexible conception of the members of a group or subgroup is the definition of which of the following terms? a. ethnocentrism b. stereotype c. cultural sensitivity d. ethnicity

B

Asking a colleague to recheck a blood pressure to see if he/she gets a similar reading as you, is an example of which of the following? a. Reflection b. Validation c. Interpretation d. Documentation

B

Crackles in the lungs, 1/3 up bilaterally and +4 pitting edema of the lower legs bilaterally are indications of what condition? A. Dehydration B. Heart failure C. Asthma D. Tuberculosis

B

During which part of the interview would the nurse ask a patient questions about a current illness? a. Introductory phase b. Working phase c. Termination phase d. Building phase

B

Edema of the lower leg which creates an indentation which persists 30 seconds or more when prodded by your finger may be classified as which of the following? a. +1 pitting edema b. +4 pitting edema c. Nonpitting edema d. Inflammation

B

For which one of the following assessments would the nurse need to use a stethoscope? a. Assessing for excess fluid in the abdomen b. Assessing for bruits in the carotid artery c. Assessing the border of the liver d. Assessing for cyanosis in the finger tips

B

Hard, contracting muscles may be described by which term? a. Hypotonicity b. Hypertonicity c. Atrophy d. Hypertrophy

B

Physical assessment provides which type of data? a. Subjective b. Objective c. Symptoms d. Current medical history

B

Testing for the air conduction of sound vs the bone conduction of sound using a tuning fork is which one of the following tests? a. Weber test b. Rinne test c. Cover/uncover test d. Ischiara test

B

The diastolic blood pressure is a reflection of what physiologic function? a. The contraction of the ventricles of the heart b. The relaxation of the ventricles of the heart c. The minimum pressure present at all times within the arteries d. An average of the systolic pressure and the pulse pressure

B

The elbow is an example of which of the following joints? a. Ball and socket b. Hinge c. Saddle d. Amphiarthrotic

B

The increase in base angle of the finger nails and loss of the diamond when placing the fingers of opposite hands together is called by which term? a. Hitting b. Clubbing c. Nailing d. Normal

B

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document this finding as . . . a. pectus thorax b. pectus excavatum c. pectus carinatum d. pectus diaphragm

B

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible . . . a. aortic aneurysm b. paralytic ileus c. gastroentertitis d. fluid and electrolyte imbalances

B

The nurse is interviewing for the first time, a Hispanic patient with limited English skills. The nurse observes that the patient is reluctant to reveal personal information and that he believes in a hot-cold syndrome of disease causation. What should the nurse do in this situation? a. Request a family member interpret for the patient b. Indicate acceptance of the patient's cultural differences c. Use slang terms to identify certain body parts d. Remain in a standing position during the interview

B

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to do which of the following? a. Inhale deeply b. Swallow a small sip of water c. Cough deeply d. Flex the neck to each side

B

The nurse is preparing to assess the respirations of an alert adult client. The nurse should a. explain to the client that he or she will be counting the client's respirations b. unobtrusively observe for the equal bilateral chest expansion while continuing to palpate the radial pulse site c. count fo 15 seconds and multiply the number by 4 to obtain the rate d. ask the client to lie in a supine position, which makes counting the respirations easier

B

The nurse is preparing to perform a head and neck assessment of an adult patient who has immigrated to the United States from Cambodia. What should the nurse do first? a. Explain to the patient why the assessment is necessary b. Ask the patient if touching the head is permissible c. Determine whether the patient desires a family member present d. Examine the lymph nodes of the neck before examining the head

B

Upon inspection of a 55 year old female client's breasts, superficial venous patterns are noted in each breast bilaterally. The nurse documents this finding as . . . a. A possible malignancy b. A normal finding c. The client is pregnant d. Abnormal, requiring more testing

B

What does blood pressure measure? a. The flow of blood through the circulation b. The force of blood against the artery walls c. The force of blood against the venous walls d. The flow of blood through the heart

B

What is the range of motion term for moving toward the body? A. Abduction B. Adduction C. Inversion D. Flexion

B

What is the respiratory effort usually exhibited by a client with metabolic acidosis (such as diabetic ketoacidosis) called? a. Apnea b. Kussmaul breathing c. Cheyne-Stokes breathing d. Paroxysmal nocturnal dyspnea

B

What is the term for a bluish cast to the skin due to deoxyhemoglobin or loss of oxygen? A. Jaundice B. Cyanosis C. Erythema D. Pallor

B

A nurse is collecting data from an older adult patient as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? Select all that may apply. a. Slower light touch sensation b. Some vision and hearing decline c. Slower fine finger movement d. Some short-term memory decline e. Slower superficial pain sensation

B, C, D

A bluish hue to the skin and nails that develops as a result of decreased blood flow to an area as seen in cold conditions for example is called which term? a. Jaundice b. Central cyanosis c. Peripheral cyaanosis d. Melanin

C

A breast mass that is tender, mobile, round and well-delineated would probably classified as which type of breast condition? a. Breast Cancer b. Fibroadenoma c. Fibrocystic disease d. A lactating breast

C

A criterion for testing the adequacy of a client's visual fields is which one of the following? a. The ability to discriminate primary colors b. The lack of floaters across the field of vision c. The correspondence to visual fields of the examiner, if the examiner has normal visual fields d. The ability to read

C

A male patient complains of pain in his genital area. Upon inspection and palpation, the patient's scrotum is enlarged, reddened, and tender. The nurse suspects which of the following conditions? a. Hydrocele b. Spermatocele c. Orchitis d. Testicular tumor

C

A paralytic ileus may present with which one of the following bowel sounds? A. Hyperactive B. Borborygmi C. Hypoactive D. Active, present at 15/minute

C

A patient is noted to be leaning forward with his arms supporting his body weight as the nurse enters the exam room. For what disease process should the nurse assess the patient for completely? a. Diabetes mellitus b. Heart failure c. Chronic obstructive pulmonary disease (COPD) d. Systemic lupus erythematosus

C

A statement such as "OK, now I want to discuss your sleep and rest patterns" is an example of which component of the interviewing process? The use of a . . . a. Leading question b. Direct question c. Transitional phrase d. Closing remark

C

An infection of the middle ear is called which of the following? a. Otitis externa b. Ototoxcity c. Otitis media d. Presbycusis

C

During a physical examination of an adult client, when should the nurse auscultate the client's abdomen? a. After palpating the abdomen but before percussion b. After percussing the abdomen c. After inspection of the abdomen and before palpation d. First, before Inspection, Palpation, and Percussion

C

During an eye assessment, you gently palpate the eyeball through the closed eyelid and note a firm, nonmobile eyeball. What does this finding possibly indicate? a. Conjunctivitis b. Cataracts c. Glaucoma d. This is a normal finding, indicating proper alignment

C

For the nurse to be therapeutic with patients when discussing sensitive issues such as terminal illness or sexuality, the nurse should have which of the following? a. Advanced preparation in these areas b. Experience dealing with these types of patients c. Knowledge of his/her own thoughts and feelings about these issues d. Personal experiences with death, dying, and sexuality

C

Having the patient stand with their feet together and eyes closed is which of the following tests? a. Tandem gait b. Pronator drift c. Romberg d. Palmar drift

C

How would you characterize a Grade VI cardiac murmur? a. Very faint b. Very loud, heard with stethoscope only c. Very loud, audible with stethoscope not in direct contact with chest d. Loud, no thrill

C

Pain that is diffuse, hard to pinpoint, and originates from organs is classified as which type of pain? a. Cutaneous pain b. Deep somatic pain c. Visceral pain d. Radiating pain

C

Raising the arms up from side and then down across body is testing which of the following? a. Flexion/extension of the shoulder b. Internal/external rotation of the shoulder c. Abduction/adduction of the shoulder d. Inversion/eversion of the shoulder

C

Rapid alternating movements such as "flapjacks" are assessing which part of the brain? a. Frontal lobe b. Parietal lobe c. Cerebellum d. Brain stem

C

Sharp, stabbing pain, and shiny, hairless skin is associated with which cardiovascular condition? A. Heart attack B. Mitral valve insufficiency C. Arterial insufficiency D. Venous insufficiency

C

The mental status exam has which one of the following assessments as a component? a. Romberg test b. Eye movements c. Orientation d. Proprioception

C

The nurse is preparing to auscultate the posterior thorax of an adult female client. What should the nurse do to correctly assess breath sounds? a. Place the bell of the stethoscope firmly on the posterior chest wall b. Auscultate from the base of the lungs to the apices c. Ask the client to breathe deeply through her mouth d. Ask the client to breathe normally through her nose

C

What are bony overgrowths of the DIP joints called? A. Fusiform fingers B. Bouchard nodes C. Heberden nodes D. Swan neck deformities

C

What does a positive straight leg raise test usually indicate? A. Leg length discrepancy B. Improperly conditioned muscles C. Lumbar nerve root irritation D. Hip bursitis

C

What is a brief statement of the reason a person is seeking health care called? A. Medical history B. Past medical history C. Chief complaint D. Personal history

C

What is considered an abnormal response to the "Doll's Eyes" test for comatose clients? a. The eyes close when the head is flexed. b. The eyes deviate in the opposite direction when the head is turned left or right c. The eyes do not deviate when the head is turned left or right. d. The eyes blink when the head is turned right or left.

C

What is the correct procedure for performing the Weber test? A. Place a tuning fork first on the mastoid process and then, when the client no longer hears it, near the external canal B. Whisper two syllable numbers while occluding one of the client's ears C. Place a tuning fork on the center of the client's head and ask where the sound is heard more prominently D. Using an audiometer, select a decibel level and check different frequencies from low to high

C

What is the finger-to-nose test assessing? a. Sensory function b. Point location c. Coordination d. Mental status

C

What is the policy called that requires using protective measures to minimize the exposure to potentially infectious body fluids? a. hand washing b. body substance isolation c. standard precautions d. common sense

C

What should the nurse do to complete an order for orthostatic vital signs on a patient? Have the patient lie down, sit up, then stand up and record the patient's . . . a. Pulse only b. Blood pressure only c. Pulse and blood pressure noted in each position d. The pulse pressure noted in each position

C

When assessing a patient for pain, which of the following is the best action the nurse should take? a. Doubt the patient when he/she describes the pain unless the patient is grimacing. b. Assess for underlying causes of pain, then believe the patient. c. Believe the patient whenever he/she claims to be in pain. d. Assess for physiologic indicators of pain, then believe the patient.

C

When setting the stage and then managing the interview, which of the following is it imperative to do? a. Take extensive notes during the interview so details are not missed b. Greet the client by their first name to increase comfort c. Introduce yourself and your role, usually before the client undresses d. Warn the client that you cannot guarantee confidentiality

C

Where does the nurse palpate to assess a patient's posterior tibial pulse? a. Behind the knee b. Top of the foot c. Medial ankle d. In the groin

C

Which age group is the prevalence of testicular cancer the highest? a. Males age 65 to 75 b. Males age 35 to 50 c. Males age 15 to 30 d. Males age 5 to 10

C

Which of the following are indicative of a left Deep Vein Thrombosis (DVT) in a patient? a. Cold, blue left foot b. Absent pulse in the left foot c. Edema, redness, and warmth of the left leg d. Pale, hairless, lower left leg

C

Which of the following techniques is most likely to result in the improved understanding for the patient of the interviewer's questions? a. The use of phrases that are commonly used by other client's in the area. b. The use of the client's own terms if possible. c. The use of the simplest language possible d. The use of the correct medical and technical terminology

C

Which one of the following factors is most important to consider while the nurse is interacting with patients? a. The atmosphere of the interview area b. The time you have to spend with the client c. The nurse's feelings, such as anger or disgust d. The nurse's need to be accepted by your clients

C

Which one of the following is a "normal" finding during a physical assessment? a. Unilateral nipple inversion of the breasts b. Discharge from the urethral meatus of the penis c. Dense, firm, elastic tissue of the female breast d. Bulging of the posterior wall of the vagina

C

With which condition is a venous star associated? a. Liver disease b. Aging c. Increased pressure in veins d. Trauma

C

A nurse is preparing to assess a young adult male patient's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that may apply. a. A concave thoracic spine posteriorly b. An exaggerated lumbar curvature c. A concave lumbar spine posteriorly d. An exaggerated thoracic curvature e. Muscles slightly larger on the patient's dominant side

C, E

A description of a lesion grouping or configuration as localized and following a nerve path or dermatome would be classified as which one of the following? a. Annular b. Arcuate c. Discoid d. Zosteriform

D

A patient is diagnosed with hypertrophic cardiomyopathy - -a disease leading to an enlarged heart. While palpating the apical pulse or point of maximal impulse (PMI) for this patient, the nurse may note which of the following findings? The PMI is located at the . . . a. Second ICS, just left of the sternum b. Second ICS, lateral to the MCL c. Fifth ICS, just left of the sternum d. Sixth ICS, just medial to the AAL

D

A patient visiting the clinic tells the nurse that she has had lower back pain for the past several days. The nurse suspects a herniated disk with resultant lumbar nerve root pressure. Which test can the nurse perform to help confirm this suspicion? a. Brudzinski's test b. Kernig's test c. Phalen's test d. Lasegue's test

D

A tingling sensation radiating from the wrist to the hand upon striking the median nerve is which one of the following signs? a. A positive Homan's sign b. A positive Rhomberg sign c. A positive Phalen sign d. A positive Tinel sign

D

Acne is which type of skin lesion? A. Vesicle B. Bulla C. Wheal D. Pustule

D

An impairment of postural sense, as in being intoxicated, is which of the following terms? a. Agnosia b. Apraxia c. Aphasia d. Ataxia

D

During a musculoskeletal assessment, for which one of the following parameters are you examining each joint? a. Pain and swelling b. Warmth and redness c. Deformity and/or crepitus d. All of these

D

If a client cannot shrug his/her shoulders against resistance, which cranial nerve requires further evaluation? A. CN 5, Trigeminal B. CN 6, Abducens C. CN 10, Vagus D. CN 11, Spinal Accessory

D

Pinching the skin between the fingers at the collarbone and noting the tenting is assessing for which parameter? a. Pitting edema b. Tensile strength c. Warmth and moisture d. Turgor

D

Rhonchi adventitious sounds are heard when auscultating a patient's lungs. Which one of the following actions should be done first by the nurse? a. Refer the patient for further medical evaluation b. Auscultate for egophony c. Perform bronchophony d. Have the patient cough, then auscultate lungs again

D

The Oculocephalic Reflex is assessing which part of the brain? a. Cerebrum b. Cerebellum c. Diencephalon d. Brain stem

D

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for which possible condition? a. liver disease b. abdominal distention c. Cushing's syndrome d. internal bleeding

D

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. the nurse suspects that the client is experiencing a. lordosis b. arthritis c. kyphosis d. scoliosis

D

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should . . . a. perform this abdominal assessment first b. ask the client to assume a side-lying position c. palpate lightly while slowly releasing pressure d. palpate while quickly releasing pressure

D

The nurse is planning to percuss the back of an adult male client for diaphragmatic excursion. How should the nurse begin the assessment? a. Ask the client to take a deep breath and hold it b. Percuss upward from the base of the lungs c. Percuss downward until the tone changes from dull to resonance d. Ask the client to exhale forcefully and hold his breath

D

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to assume which of the following positions? a. Lie in a supine position b. Lie in a side-lying position c. Stand upright in front of the nurse d. Sit in an upright position

D

The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. the nurse determines that the client needs further instructions when the client says which of the following? a. "You will be asking me to change positions often." b. "You will be comparing bilateral joints." c. "You will be assessing the size and strength of my joints." d. "You will continue with range of motion even if I have discomfort."

D

The nurse obtains a diastolic blood pressure reading of 110 mmHg for an adult patient. Which action should the nurse do first regarding this reading? a. Document findings: the reading is within the normal range for an adult b. Document findings: although the reading is at the lower end of the BP range, the physician does not need to be notified c. Document findings: then monitor the patient's vital signs every 8 hours d. Document findings: notify the physician

D

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of which vitamin? a. A b. B12 c. C d. D

D

To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's . . . a. left upper quadrant b. left lower quadrant c. right upper quadrant d. right lower quadrant

D

Uncoordinated or "crossed" eyes are denoted with which one of the following terms? A. Exopthalmos B. Presbyopia C. Amplyopia D. Strabismus

D

When assessing the cranial nerves 3 through 12, which part of the brain is the nurse assessing? a. Cerebellum b. Cerebral cortex c. Diencephalon d. Brain stem

D

Which of the following is not a "normal" curvature of the spine? a. Cervical - concave b. Thoracic - convex c. Lumbar - concave d. Sacral - concave

D

Which of the following joints is the only one that both sides of the body must work together at the same time? a. Shoulder b. Hip c. Ankle d. Temporal-mandibular

D

Which of the following joints represents an example of a ball and socket joint? a. Ankle b. Thumb c. Elbow d. Hip

D

Which on the of the following groups is very time conscious and maintains eye contact while speaking to another person? a. Asian b. African-American c. Hispanic d. Euro-American

D

Which sense is utilized when doing palpation as an assessment technique? a. Vision b. Hearing c. Smell d. Touch

D

While inspecting the perianal area of a patient, a small dimple with a tuft of hair is noted sacrococcygeal area. The nurse documents this finding as a . . . a. Hemorrhoid b. Perianal abscess c. Rectal Cancer d. Pilonidal cyst

D

With aging, blood pressure is often higher due to which of the following? a. Loss of muscle mass b. Changes in exercise and diet c. Decreased peripheral resistance d. Decreased elasticity in arterial walls

D

You assess a client's vision to be 20/50 in both eyes. What does this mean? a. Your client can see 50% of what the average person sees at 20 feet b. Your client has perfect vision when tested at 50 feet c. Your client can see 20% of the letters on the charts 20/50 line d. Your client can read letters while standing 20 feet from the chart that the average person could read at 50 feet

D

he diencephalon of the brain consists of the . . . a. pons and brain stem b. medulla oblongata and cerebrum c. cerebellum and midbrain d. thalamus and hypothalamus

D

The nurse notes the right leg of a patient is rated +3 when checking muscle strength. Which of the following is the correct interpretation of this rating? a. Active movement against full resistance b. Barely detectable, flicker of contraction c. Active movement of part with gravity eliminated d. Active movement against gravity and some resistance e. Active movement against gravity

E