Health Assessment Exam 2
Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is increased in patients with alcoholism? Select all that apply. A. Esophageal cancer B. Stomach cancer C. Pancreatic cancer D. Liver cancer E. Colon cancer F. Bladder cancer
A, B, D, E Pancreatic and bladder cancer are an increased risk with tobacco
Which questions are appropriate for a symptom analysis of a patient with benign prostatic hyperplasia? (Select all that apply.) A. "How often have you found that you stopped and started again several times when you urinated?" B. "How often have you had to urinate again less than 2 hours after you finished urinating?" C. "How often have you been incontinent of urine?" D. "How often have you had constipation due to the enlarged prostate?" E. "How often have you had to push or strain to begin urination?" F. "How often have you had to get up during the night to urinate?"
A, B, E, F
Nurses inquire about lifestyle behaviors in those patients with specific risk factors for cataracts. Which characteristics are associated with risk factors for cataracts? (Select all that apply) A. Smoking more than 20 cigarettes a day B. Having parents with cataracts C. Chronic consumption of alcohol D. Having a chronic disease, such as diabetes mellitus E. Being asian F. Being a man
A, C, D
What are the functions of the upper airways? (Select all that apply.) A. Conduct air to lower airway B. Provide area for gas exchange. C. Prevent foreign matter from entering respiratory system. D. Warm, humidify, and filter air entering lungs. E. Provide transportation of oxygen and carbon dioxide between alveoli and cells.
A, C, D B-Gas exchange occurs in the alveoli. E-The cardiovascular system provides transportation of oxygen and carbon dioxide between alveoli and cells
Which lifestyle behaviors do nurses ask about to identify patients with risk factors for breast cancer? (Select all that apply.) A. Obesity after age 50 B. Smoking more than one pack of cigarettes a day C. Never having given birth to a viable infant D. Drinking two to five alcoholic beverages a day E. Estrogen replacement therapy for more than 5 years F. High blood pressure for more than 3 years
A, C, D, E
A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? (Select all that apply.) A. Thoracic expansion that is symmetric bilaterally B. Respiratory rate of 24 breaths/min C. Bronchophony revealing clear voice sounds D. Breath sounds clear with vesicular breath sounds heard over most lung fields E. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter F. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine
A, D, E, F
What findings does the nurse expect when assessing the ears of a healthy adult? (select all that apply) A. Cerumen noted in the outer ear canal B. Pinna located below the external corner of the eye C. Cone of light located in the 5 o' clock position in the left ear D. Ratio of air conduction to bone conduction 2:1 E. Tympanic membrane pearly gray F. Whispered words repeated accurately
A, D, E, F
A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms? A. "Do you have the feeling that you cannot wait to urinate?" B. "Are you urinating a large amount each time you go to the bathroom?" C. "Has the color of your urine changed lately?" D. "Have you noticed any swelling in your ankles at the end of the day?"
A. "Do you have the feeling that you cannot wait to urinate?"
During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data? A. "Does the sputum have an odor?" B. "Do you have chest pain when you take a deep breath?" C. "Have you also experienced tightness in your chest?" D. "Have you coughed up any blood?"
A. "Does the sputum have an odor?" B-pleural lining irritation C-asthma D-lung cancer
A 50-year-old patient asks the nurse about her risk of developing a cancer of the reproductive system. What is the appropriate response by the nurse? A. "Human papilloma virus infection and cigarette smoking are major risk factors for cervical cancer." B. "Some of the risk factors for endometrial cancer include being age 40 or older and having a history of infertility." C. "Ovarian cancer is not often seen in women under age 50 or those who have a family history of breast cancer." D. "Women who have had menstrual irregularities for many years are at lower risk of developing any of the reproductive system cancers."
A. "Human papilloma virus infection and cigarette smoking are major risk factors for cervical cancer."
During system analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? A. "I felt faint, like I was going to pass out." B. "It feels like I was on a merry-go-round." C. "The room seem to be spinning around." D. "My body felt like it was revolving and could not stop."
A. "I felt faint, like I was going to pass out."
The nurse recognizes which patient has the highest risk of endometrial cancer? A. A 24-year-old woman with menarche at age 9 B. A 30-year-old woman who started menstruating at age 19 C. A 42-year-old woman who reached menopause at age 40 D. A 64-year-old woman who had irregular, heavy menstrual cycles
A. A 24-year-old woman with menarche at age 9 Early menarche is a risk factor.
After taking a brief health history, a nurse needs to complete a focused assessment on which patient? A. A male who works as painter B. A male who plays basketball and hockey C. A female who recently moved into a college dormitory D. A female who has a history of gout
A. A male who works as painter - The fumes and chemicals from the paint may expose the patient to respiratory irritants. A baseline pulmonary assessment needs to be documented
While giving a history, a patient reports having a weak urinary stream and feeling that his bladder is not empty after urination. Based on these data, what finding does the nurse anticipate upon examination? A. An enlarged prostate gland palpated on the anterior wall of the rectum B. An indirect hernia palpated through the inguinal ring when the patient coughs C. The foreskin of the penis cannot be returned to position after retraction behind the glans D. A nodular prostate gland palpated on the posterior wall of the rectum
A. An enlarged prostate gland palpated on the anterior wall of the rectum
What signs of cyanosis does a nurse inspect for in a dark-skinned patient? A. Ashen-gray color of the oral mucous membranes B. Blue color in the nail beds C. Ashen blue color in the palms and soles D. Blue-gray color in the ear lobes and lips
A. Ashen-gray color of the oral mucous membranes
During a breast examination of a male patient, the nurse recognizes which finding as normal? A. Bilateral nontender flat breasts with symmetric nipple and areolar areas B. A fibrous layer of subcutaneous breast tissue that is thicker than in women C. Breast tenderness on the dominant side but not on the other side D. Bilateral symmetry of breasts with absence of hair in the areolar areas
A. Bilateral nontender flat breasts with symmetric nipple and areolar areas
A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation? A. Bronchophony reveals the patient's spoken "99" as clear and loud. B. No sounds are expected since sounds cannot be transmitted through consolidation. C. Egophony reveals indistinguishable sounds when the patient says "e-e-e." D. Whispered pectoriloquy reveals a muffled sound when the patient says "1-2-3."
A. Bronchophony reveals the patient's spoken "99" as clear and loud.
In assessing a patient with suspected Chlamydia, the nurse's actions are guided by which characteristic of this disease? A. Chlamydia is frequently asymptomatic and requires screening. B. Chlamydia is associated with a yellow-green vaginal discharge. C. Chlamydia is accompanied by heavy bleeding and headache. D. Chlamydia is only seen in immunocompromised patients.
A. Chlamydia is frequently asymptomatic and requires screening.
A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? A. Clear B. Malodorous C. Yellow D. Green
A. Clear allergic rhinitis B, C & D: bacterial infection
A nurse performing a breast examination on a female patient places the patient in a supine position, places a pillow under the right shoulder, and asks the patient to place her right lower arm above her head. What is the reason for this position? A. Flatten the breast tissue evenly over the chest wall. B. Help the patient to relax and feel more comfortable. C. Reveal lumps deep in the breast more easily. D. Expose any drainage from the nipples.
A. Flatten the breast tissue evenly over the chest wall.
A patient tells the nurse, "I've been having pain in my belly for several days that gets worse after eating." Which datum from the symptom analysis is consistent with the nurse's suspicion of peptic ulcer disease? A. Gnawing epigastric pain radiates to the back or shoulder that worsen B. Sharp midepigastric pain radiates to the jaw C. Intermittent cramping pain in the left lower quadrant is relieve by defecation D. Colicky pain is felt near the umbilicus with vomiting and constipation.
A. Gnawing epigastric pain radiates to the back or shoulder that worsen
The nurse recognizes which clinical finding as expected on palpation of the abdomen? A. Inability to palpate the spleen B. Left kidney rounded at 2 cm below the costal margin C. Slight tenderness of the gallbladder on light palpation D. Bounding pulsation of the aorta over the umbilicus
A. Inability to palpate the spleen
After assessment of the nose and paranasal sinuses, which finding requires further investigation by the nurse? A. Nasal septum off the midline B. Nose in the midline of the face C. Middle turbinates deep pink in color D. Noiseless exchange of air from each naris
A. Nasal septum off the midline
A patient reports having a migraine headaches on one side of the head that often starts with an aura and last 1 to 3 days. As part of the system analysis, the patient reports which associated symptoms of migraine headaches? A. Nausea, vomiting, or visual disturbances B. Nasal stuffiness or discharge C. Ringing in the ears or dizziness D. Red, watery eyes or drooping eyelids
A. Nausea, vomiting, or visual disturbances
A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of healing. What is the most appropriate action for the nurse at this time? A. Obtain further data now to rule out abuse B. Remind parents that toddlers are clumsy and may fall, causing bruising C. Determine if this toddler has a coagulation disorder D. Recommend further observation at future visit
A. Obtain further data now to rule out abuse
Based on the history, a nurse determines that the patient with which finding requires further assessment? A. Occasional discharge from nipples B. Supernumerary nipples along the milk line C. Rash in the axillae associated with change in deodorant D. Mild breast swelling that fluctuates with the menstrual cycle
A. Occasional discharge from nipples
Which cranial nerve is assessed by using the Snellen visual acuity chart? A. Optic cranial nerve (CN II) B. Oculomotor cranial nerve (CN III) C. Abducens cranial nerve (CN IV) D. Trochlear cranial nerve (CN VI)
A. Optic cranial nerve (CN II) CN III, CN IV, CN VI= control eyeball movement
A nurse expects to find which manifestations in the male patient who has both Chlamydia and gonorrhea? A. Painful urination and purulent urethral discharge B. A single, firm painless open sore on the shaft of the penis C. Red superficial vesicles on the shaft of the penis D. A single or a cluster of wartlike growth in the anal-rectal area
A. Painful urination and purulent urethral discharge B- syphilis C- herpes genitals D- HPV
A nurse notices abdominal distention when inspecting a patient's abdomen. What action does the nurse take next to gain further objective data? A. Place a measuring tape around the superior iliac crests. B. Assist the patient to turn on to the left side and then the right side. C. Ask the patient to cough while lying supine. D. Use the fingertips to sharply strike one side of the abdomen.
A. Place a measuring tape around the superior iliac crests.
When the patient's chart include a notation that petechiae are present, what finding does a nurse expect during inspection? A. Purplish-red pinpoint lesions B. Deep purplish or red patches of skin C. Small raised fluid-filled pinkish nodules D. Generalized reddish discoloration of an area of skin
A. Purplish-red pinpoint lesions
While giving a history, the patient reports having herpes genitalis. Based on this information, which finding does the nurse anticipate during the assessment? A. Small vesicles on the genitalia B. Single, firm, painless, open sore C. Pain when palpating the cervix D. Malodorous greenish-yellow vaginal discharge
A. Small vesicles on the genitalia B- syphilis C- Chlamydia D- trichomonas
On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes tenderness. This finding may indicate a disorder in which organ? A. Spleen B. Gallbladder C. Sigmoid colon D. Left ovary
A. Spleen
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding? A. The extraocular muscles of both eyes are intact. B. The cornea of each eye is transparent. C. The sclera of each eye is clear. D. The consensual reaction of both eyes is intact.
A. The extraocular muscles of both eyes are intact.
In educating a male patient about testicular cancer, the nurse includes which statement? A. The highest incidence of this cancer is in men between 20 and 34 years of age. B. The incidence of this cancer is correlated with human papillomavirus (HPV) infection. C. The risk of this cancer increases with multiple sexual partners. D. This type of cancer more commonly affects uncircumcised males.
A. The highest incidence of this cancer is in men between 20 and 34 years of age.
Which patient should the nurse assess first? A. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. B. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever. C. The patient who is short of breath, using pursed-lip breathing, and in a tripod position. D. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and expiratory wheezes.
A. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. Pneumothorax
The nurse correlates which factor to an increased risk of endometrial cancer in women with early menarche or late menopause? A. Total number of ovulatory cycles B. Less hormone stimulation C. Need for estrogen replacement in these patients D. Extended duration of the menstrual cycle in these patients
A. Total number of ovulatory cycles More ovulatory cycles increases risk. These risk factors represent an increased cumulative exposure to estrogen.
A patient has come to the clinic complaining of a bump behind his right ear. Upon inspection, the nurse notes a lesion that is elevated, solid, and 4cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider? A. Tumor B. Nodule C. Keloid D. Papule
A. Tumor
Which sound does a nurse expect to hear when percussing a patient's abdomen? A. Tympany over all quadrants B. Resonance over the upper quadrants and tympany in the lower quadrants C. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants D. Dull sounds over the stomach and resonant sounds over the bladder
A. Tympany over all quadrants
A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs? A. Vesicular breath sounds heard in peripheral lung fields B. Bronchial breath sounds heard over the bronchi C. Bronchovesicular breath sounds heard over the apices D. Rhonchi heard over the main bronchi
A. Vesicular breath sounds heard in peripheral lung fields vesicular breath sounds heard in peripheral lung fields are an expected finding for healthy lungs B-over the trachea C- near sternal border and 2nd intercostals space D- Rhonchi are adventitious sounds indicating secretions in the bronchi.
Which patients meet the criteria for Chlamydia screening? (Select all that apply.) A. A 40-year-old woman who is sexually active and uses barrier protection consistently B. A 15-year-old female woman who is sexually active with one partner C. A 22-year-old woman who is sexually active and uses barrier protection inconsistently D. A 23-year-old woman who has had four sexual partners in the last 3 months E. A 34 year-old woman who uses barrier protection inconsistently with multiple sexual partners F. A 36-year-old pregnant woman making the first prenatal visit
B, C, D, E, F
In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient? A. "Have you had any pain in your abdomen?" B. "Have you had an unexpected weight gain?" C. "Have you noticed a change in the color of your skin?" D. "Have you had any nausea or vomiting?"
B. "Have you had an unexpected weight gain?"
A patient reports having abdominal distention. The nurse notices that the patient's sclerae are yellow. What question is appropriate for the nurse to ask in response to this information? A. "Has there been a change in your usual pattern of urination?" B. "Have you had any nausea or vomiting?" C. "Has there been a change in your bowel habits?" D. "Have you had indigestion or heartburn?"
B. "Have you had any nausea or vomiting?"
Which question will give the nurse additional information about the nature of a patient's dyspnea? A. "How often do you see the physician?" B. "How has this condition affected your day-to-day activities?" C. "Do you have a cough that occurs with the dyspnea?" D. "Does your heart rate increase when you are short of breath?"
B. "How has this condition affected your day-to-day activities?"
A patient asks when she can stop having Pap (Papanicolaou) tests. What is the nurse's most appropriate response? A. "Until you are no longer sexually active." B. "Through age 65." C. "Until you begin menopause." D. "Through the end of menopause."
B. "Through age 65." This is the recommendation from the U.S. Preventive Services Task Force. All females should be screened after the onset of sexual activity through age 65.
In receiving the charts of several patients in the clinic, a nurse recognizes which patient as being at highest risk of breast cancer? A. A woman who had her first child at age 26 B. A woman who reached menopause at 58 C. A woman who breastfed all four of her children D. A woman who states that she reached menarche at age 14
B. A woman who reached menopause at 58
A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time? A. Palpate the posterior thorax for vocal fremitus. B. Ask the patient to cough and repeat auscultation. C. Auscultate the posterior thorax for vocal sounds. D. Percuss the posterior thorax for tone.
B. Ask the patient to cough and repeat auscultation. the sounds indicate rhonchi, or secretions in the bronchi. The first action to take is to determine if the rhonchi clear with coughing. If the rhonchi clear, there is no need to further investigate this finding.
A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection? A. Tinnitus, vertigo, and dizziness B. Clear drainage from the ear and nose C. Loss of hearing and smell D. Purulent drainage from the ear and bloody drainage from the nose
B. Clear drainage from the ear and nose This may occur after a basilar skull fracture; the clear drainage may be cerebrospinal fluid
A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patient's integumentary system, what finding should the nurse correlate to this respiratory disease? A. Dry, flaky skin B. Clubbing of the fingers C. Hypertrophy of the nails D. Hair loss from the scalp
B. Clubbing of the fingers A- dehydration C-repeated trauma D-systemic diseases
What technique does a nurse use when palpating the right lobe of a patient's thyroid gland using the anterior approach? A. Pushes the cricoid process to the left with the right thumb B. Displaces the trachea to the right with the left thumb C. Manipulates the thyroid between the thumb and index finger D. Moves the sternocleidomastoid muscle to the right with the left thumb
B. Displaces the trachea to the right with the left thumb
What normal finding does a nurse expect to find when palpating a male patient's prostate gland? A. Is approximately 4.5 cm in diameter and is highly mobile B. Feels smooth, firm, and slightly mobile C. Is deeply divided into three lobes, each approximately 2 cm in length D. Feels hard, asymmetrical, and has a palpable ridge that divides the gland into two lobes
B. Feels smooth, firm, and slightly mobile
A patient complains of dysuria, yellow-green vaginal discharge, and vulvar itching. The nurse suspects which sexually transmitted disease?A. Syphilis B. Gonorrhea C. Genital warts D. Chlamydia
B. Gonorrhea Gonorrhea causes a yellow or green vaginal discharge, dysuria, pelvic or abdominal pain, and vaginal itching and burning.
During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis? A. Have you noticed any swelling in your ankles or feet at the end of the day? B. Have you noticed a change in the color of your urine or stool? C. Have you vomited up any blood in the last 24 hours? D. Have you experienced fever, chills, or sweating?
B. Have you noticed a change in the color of your urine or stool?
How does the nurse accurately assess bowel sounds? A. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant. B. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant. C. Press the bell of the stethoscope firmly against the abdomen in each quadrant. D. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.
B. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.
A patient is admitted with edema of the occipital lobe following a head injury. The nurse correlates which finding with damage to this area? A. Ipsilateral ptosis B. Impaired vision C. Pupillary constriction D. Increased intraocular pressure
B. Impaired vision the occipital lobe contains the visual context
What technique does a nurse use when performing a breast examination on a patient who has had a mastectomy? A. Excludes palpation of the axillary area where there was lymph node dissection B. Inspects and palpates both the operative and the nonoperative sides C. Avoids palpating the scar to prevent causing the patient any discomfort D. Palpates only the muscle tissue on the affected side
B. Inspects and palpates both the operative and the nonoperative sides
A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma? A. Non-blanching lesion B. Irregular border C. Diameter less than 5mm D. Black color of the lesion
B. Irregular border
A patient had a left radical mastectomy last year. The nurse assesses for painless and nonpitting swelling of the arm on that side. Which complication of a mastectomy is the nurse assessing for? A. Infection B. Lymphedema C. Inflammation D. Lymphoma
B. Lymphedema
A nurse shines a light toward the bridge of the patients nose and notices that the light reflection in the right cornea is at the 2 o' clock position and in the left cornea at the 10 o' clock position. Based on these data, the nurse should take what action? A. Document these findings as normal B. Perform the cover-uncover test C. Perform the confrontation test D. Document these findings as abnormal
B. Perform the cover-uncover test
How does the nurse perform a Weber test to assess hearing function? A. Whispers three to four words into the patient's ear and asks him to repeat the words heard B. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears C. Places a set of headphones over both ears, plays several tones and asks the patient to identify the sounds D. Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the sound
B. Places a set of headphones over both ears, plays several tones and asks the patient to identify the sounds A-Whisper test C-the use of audiometer D-part of Rinne test
To assess jaw movement of an adult patient, the nurse uses which technique? A. Asking the patient to open the mouth and then passively moving the patient's open jaw from side to side B. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth C. Asking the patient to open the mouth and to resist the nurse's attempt to close the mouth D. Using the pads of all fingers to feel along the mandible for tenderness and nodules
B. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth A- active, not passive C- strength of the jaw D- reveal submental lymph node
A patient who complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which during examination? A. Foul-smell drainage B. Purulent green-yellow drainage C. Bloody drainage D. Watery drainage
B. Purulent green-yellow drainage Purulent- infection bloody- trauma watery- allergy foul-smell- foreign object in the nose
Which location does a nurse select when palpating a patient's liver? A. Right lower quadrant B. Right upper quadrant C. Left upper quadrant D. Left lower quadrant
B. Right upper quadrant
A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patients left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage? A. Stage I B. Stage II C. Stage III D. Stage IV
B. Stage II
A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem? A. The nurse documents clearly hearing the patient say "99." B. The nurse documents hearing muffled sounds when the patient says "1-2-3." C. The nurse documents hearing no sounds when the patient says "e-e-e." D. The nurse documents clearly hearing the patient say "a-a-a."
B. The nurse documents hearing muffled sounds when the patient says "1-2-3." muffled sounds of 1-2-3, e-e-e, or 99 are heard when no consolidation is found
Which patient in the eye clinic should the nurse assess first? A. The patient who reports gradual clouding of vision B. The patient who complains of sudden loss of vision C. The patient who complains of double vision D. The patient who complains of poor night vision
B. The patient who complains of sudden vision loss Sudden vision loss may indicate a detached retina, and requires immediate referral
In inspecting the scrotum, the nurse documents which finding as normal? A. The epididymides are round, solid nodular masses. B. The scrotum is deeply pigmented with a rugous surface. C. The scrotal skin is a lighter color than the body skin. D. The vas deferens is palpable bilaterally.
B. The scrotum is deeply pigmented with a rugous surface.
What is the purpose of asking a female to lean forward during the breast examination? A. To accentuate the Montgomery glands B. To observe for symmetry of the suspensory ligaments C. To compare nipple symmetry D. To identify any breast masses in the subcutaneous tissues
B. To observe for symmetry of the suspensory ligaments
In teaching a class of adolescents about sexually transmitted diseases, a nurse includes which information about the human papillomavirus (HPV)? A. HPV is fragile and not easily transmitted. B. Wartlike growths in the genital area are a sign of HPV infection. C. There is a specific blood test needed to screen for HPV. D. Heavy, purulent vaginal discharge is the primary sign of HPV.
B. Wart-like growths in the genital area are a sign of HPV infection.
The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches? A. "I usually have nausea and vomiting with my headaches." B. "My whole head is constantly throbbing." C. "It feels like my head is in a vice." D. "The pain is on the left side over my eye, forehead and cheek.
C. "It feels like my head is in a vice."
During system analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? A. "I felt faint, like I was going to pass out." B. "I just could not keep my balance when I sat up." C. "It seemed the room was spinning around." D. "I was afraid I was going to lose consciousness."
C. "It seemed the room was spinning around."
A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? A. "Has there been a change in your usual pattern of urination?" B. "Did you have heartburn before the vomiting?" C. "What did the vomitus look like?" D. "Have you noticed a change in the color of your urine or stools?"
C. "What did the vomitus look like?"
A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the nurse's most appropriate response? A. "Don't worry about it, esophageal cancers have a low incidence in men." B. "You should not be concerned about esophageal cancer at your age." C. "You should consider limiting your alcohol intake to two drinks per day." D. "Increasing the fiber and protein in your diet can help you lower your risk."
C. "You should consider limiting your alcohol intake to two drinks per day."
A mother asks a nurse when her daughter should get immunized again for human papilloma virus (HPV). What is the nurse's most appropriate response to this question? A. Your daughter does not need this immunization until she becomes sexually active B. The recommended age for this immunization is between ages 25 and 30 years of age C. Between the ages of 11 and 26 years is recommended time for this immunization D. When she begins having menstrual periods is the best time for this immunization
C. Between the ages of 11 and 26 years is recommended time for this immunization
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? A. Increased anteroposterior diameter B. Clubbing of the fingers C. Bilateral peripheral edema D. Increased tactile fremitus
C. Bilateral peripheral edema A-emphysema B-hypoxia/cystic fibrosis or COPD D-pneumonia or tumor
A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition? A. Pulmonary infection B. Trauma to the thorax C. Chronic hypoxemia D. Allergic reaction
C. Chronic hypoxemia A-acute B-Aacute D-acute
As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? A. An expected finding B. Koilonychia (spoon nail) C. Clubbing D. Leukonychia
C. Clubbing
A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time? A. Auscultate the temporal arteries for bruits B. Palpate the arteries with the patient in the supine position C. Document this as an expected finding D. Measure the patient's blood pressure
C. Document this as an expected finding
A nurse's presentation to patients on risk factors for oral cancer includes when fact? A. The peak incidence oral cancer is before 40 years of age B. Women have a higher risk than mean C. Excessive alcohol consumption is a risk factor D. Eating a low fiber diet is a risk factor
C. Excessive alcohol consumption is a risk factor A-after 40* peak 64-74 B-2:1 men to women D-risk for colon cancer
How does the nurse recognize jaundice in a dark-skinned patient? A. Inspect the conjunctiva for ashen-gray color B. Inspect the nail beds for a deeper brown or purple skin tone C. Inspect the palms and soles for yellowish-green color D. Inspect the oral mucous membrane for yellow color
C. Inspect the palms and soles for yellowish-green color A-cyanotic B-erythema D-mucous membrane does not change from jaundice
When examining the lymph nodes of an adult female patient, the nurse recognizes which finding as normal? A. Visible superficial nodes B. Palpate supraclavicular nodes C. Nonpalpable lymph nodes in the axilla D. Enlarged, fixed nodes in the neck
C. Nonpalpable lymph nodes in the axilla
The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a female patient. What is the most appropriate action for the nurse to take next? A. Record this as an expected finding. B. Palpate the area of dimpling for pain. C. Palpate the borders of the area of dimpling for irregularity. D. Tell the patient that dimpling indicates the mass is benign.
C. Palpate the borders of the area of dimpling for irregularity.
The nurse observes a patient rocking back and forth on the examination table in pain. Based on the patient's history, the nurse suspects kidney stones. What additional examination technique does the nurse perform to confirm this suspicion? A. Palpating the flank area for rebound tenderness B. Percussing the bladder for fullness C. Percussing the costal vertebral margins for tenderness D. Palpating McBurney point for tenderness
C. Percussing the costal vertebral margins for tenderness A-detect peritoneal inflammation B-detect bladder distention D-detect appendicitis
A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose? A. Deviated septum B. Pale turbinate C. Perforated nasal septum D. Localized erythema and edema
C. Perforated nasal septum Pale- allergies Deviated- birth or trauma Erythema- inflammation
A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patient's tympanic membrane to appear? A. Dull B. Shiny C. Red D. Blue to deep red
C. Red A- fibrosis or scarring B- normal D- blood behind TM, occurred secondary to injury
In assessing the breast of a male patient, the nurse places him in which position? A. Standing with hands over head B. Supine with the hand on the side being examined placed behind the head C. Sitting with arms at the side D. Bending forward 45 degrees at the waist
C. Sitting with arms at the side
While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient? A. The patient's eyes move to the left, right, up, down and obliquely during conversation B. The patient moistens the lips with the tongue C. The sides of the mouth are symmetric when the patient smile D. The patient's eyelids blink periodically
C. The sides of the mouth are symmetric when the patient smile A-CN III, IV, VI B-CN XII D-CN III
To correctly percuss the abdomen, a nurse places the distal aspect of the middle finger of the nondominant hand against the skin of the abdomen, and the other fingers are spread apart and slightly lifted off the skin. How does the nurse use the fingers of the dominant hand? A. The pad of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen. B. The tip of the middle finger strikes the nail of the middle finger touching the skin of the abdomen. C. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen. D. The pads of the index and middle fingers strike the nail of the middle finger touching the skin of the abdomen.
C. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen.
During the initial inspection of the female genitalia, the nurse recognizes which finding as normal? A. The labia minora are hair-covered and lying within the labia majora. B. The cervical os in the multiparous woman has the shape of a small circle. C. The vaginal vestibule lies between the labia minora and contains the urinary meatus. D. The openings of Skene and Bartholin glands are visible posteriorly.
C. The vaginal vestibule lies between the labia minora and contains the urinary meatus.
A nurse notices multiple lesions on a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. What kind of primary lesions are these? A. Macules B. Patches C. Vesicles D. Bullae
C. Vesicles
While taking a history of a patient with an enlarged prostate, the nurse expects the patient to report which symptom? A. Painful urination with each voiding B. Blood in the urine upon arising C. Waking from sleep to urinate D. Incontinence throughout the day
C. Waking from sleep to urinate Compression of the urethra by the enlarged prostate may cause men to be awakened from sleep to urinate (nocturia).
The nurse correlates which patient complaint with suspected enlargement of the prostate gland? A. Constipation B. Change in bowel patterns C. Weak urine stream D. Increased mucus in urine
C. Weak urine stream Enlargement of the prostate gland compresses the urethra causing a weak urinary stream.
A patient asks when she should make an appointment for her first Pap (Papanicolaou) test to screen for cervical cancer. What is the nurse's most appropriate response? A. "There is no need for Pap tests until after you have become pregnant." B. "All women should have the first Pap test after reaching menarche." C. "All women should have the first Pap test after they are 19 years of age." D. "All women should have the first Pap test when they become sexually active or at age 21."
D. "All women should have the first Pap test when they become sexually active or at age 21." This is the recommendation from the U.S. Preventive Services Task Force. All females should be screened when they become sexually active or age 21, whichever happens first.
A patient report having frequent heartburn. Which question does the nurse ask in response to this information? A. "Has your abdomen been distended when you feel the heartburn?" B. "What have you eaten in the last 24 hours?" C. "Is there a history of heart disease in your family?" D. "How long after eating do you have heartburn?"
D. "How long after eating do you have heartburn?"
Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake? A. Food diary B. Calorie count C. Comprehensive diet history D. 24-hour recall
D. 24-hour recall
Which patient does the nurse recognize as having the highest risk for ovarian cancer? A. A 24-year-old nulliparous woman who has a history of multiple sexual partners B. A 32-year-old woman who has had six live births and a history of human papilloma virus (HPV) infection C. A 55-year-old woman who reached menarche at age 12 and menopause at age 54 D. A 64-year-old nulliparous woman who has taken hormone replacement therapy for eight years
D. A 64-year-old nulliparous woman who has taken hormone replacement therapy for eight years
While giving a presentation about breast health, a nurse informs patients about which recommendation? A. Women in their 30s should have annual clinical breast examinations B. Women at high risk of breast cancer should have semiannual mammograms C. Women who are postmenopausal require clinical breast examination every 5 years D. A screening mammogram is recommended for all women beginning at age 50
D. A screening mammogram is recommended for all women beginning at age 50
A nurse examines a patient's auditory canal and tympanic membrane with an otoscope and observes which finding as normal? A. Clear fluid lining the auditory canal B. A firm tympanic membrane without fluctuation with puffs of air C. A small hole within the cone of light D. A shiny, translucent tympanic membrane
D. A shiny, translucent tympanic membrane
During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination? A. Increased tactile fremitus B. Inspiratory and expiratory wheezing C. Tracheal deviation D. An increased anteroposterior diameter
D. An increased anteroposterior diameter A- pneumonia or tumor B- asthma C- tension pneumothorax
What instructions does the nurse give a female patient when she is learning to perform breast self-examination? A. Press the pads of the fingers firmly to compress breast tissue against the rib cage. B. Lie in front of a mirror and observe for dimpling of the skin. C. Lift the fingers from the chest wall during palpation to better define the breast tissue. D. Apply gentle pressure while moving the fingers in a pattern across the breast.
D. Apply gentle pressure while moving the fingers in a pattern across the breast.
On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? A. As an indication of a type of anemia B. As a hordeolum or sty C. As jaundice D. As an expected racial variation
D. As an expected racial variation A- pale conjuctiva B- infection in sebaceous gland of eyelid C- liver or gallbladder disease
During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? A. Virus B. Allergy C. Fungus D. Bacteria
D. Bacteria A- unproductive cough B-clear sputum C-sputum obtained from tracheal aspiration
Nurses use which measurement as the most highly correlated with risk of morbidity and mortality? A. Waist to hip ratio B. Triceps skinfold measure C. Desirable body weight D. Body mass index (BMI)
D. Body mass index (BMI)
A 45-year-old woman tells the nurse that she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient? A. This is simple vellus hair and it will decrease in amount over time B. Some women in your cultural group normally have dark hair on their faces C. This is unusual; female hair distribution should be limited to arms, legs, and pubis D. Coarse dark hair could result from hormonal changes such as menopause
D. Coarse dark hair could result from hormonal changes such as menopause
A patient comes to the clinic because she found a mass in her left breast that is present during and after her menstrual periods. On palpation the nurse finds a mass in the left breast that is round, rubbery, mobile, and nontender. This finding is consistent with which breast disorder? A. Fibrocystic breast disease B. Invasive breast cancer C. Mastitis D. Fibroadenoma
D. Fibroadenoma
A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes? A. Dull sounds on percussion B. Soft, muffled rhonchi heard over the trachea C. Bubbling or rasping sounds heard over the trachea D. High-pitched sounds on inspiration and exhalation
D. High-pitched sounds on inspiration and exhalation Also known as stridor A-pneumonia, pleural effusion, or atelectasis B/C- not a description of stridor
The nurse places a male patient in which position for rectal examination? A. Lithotomy position B. Prone with the knees fully extended C. Bending over the table, with feet everted D. Left lateral position with knees and hips flexed
D. Left lateral position with knees and hips flexed
Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? A. In the lower lobes B. Over the trachea C. In the apices of the lungs D. Near the sternal border
D. Near the sternal border A- vesicular breath sounds B- bronchial sounds C-vesicular breath sounds
What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? A. Bowel sounds B. Venous hum C. Soft, low-pitched murmur D. No sounds
D. No sounds
A patient comes to the clinic complaining of a new onset of nipple discharge. After inspection of the breast and discharge, what action of the nurse has the highest priority? A. Palpating both breasts comparing amount of discharge B. Asking the patient about breast pain C. Asking the patient to raise her arms and comparing the movement of the breast D. Obtaining a specimen of the discharge for cytology
D. Obtaining a specimen of the discharge for cytology
Which patient has the lowest risk for colon cancer? A. Patient A is 50 years old, is obese, and has type 2 diabetes mellitus. B. Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily. C. Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease. D. Patient D is 45 years old and has diverticulosis.
D. Patient D is 45 years old and has diverticulosis.
During the examination of the internal genitalia with the speculum, the nurse records which finding as normal? A. A healed laceration of the cervix in a nulliparous patient B. A large amount of thick white drainage from the cervical os C. Deviation of the cervix toward the posterior vaginal wall D. Pink cervix with a small ring of reddened tissue near the os
D. Pink cervix with a small ring of reddened tissue near the os
How does the nurse perform a Rinne test of hearing function? A. Whispers three to four words into the patient's ear and asks him to repeat the words heard B. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears C. Places a set of headphones over both ears, plays several tones and asks the patient to identify the sounds D. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it
D. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it
The patient reports right lower quadrant (RLQ) pain that is worse with coughing. Based on the patient's history, the nurse suspects appendicitis. What additional examination technique does the nurse perform to confirm this suspicion? A. Placing the hand over the lower right thigh and asking the patient to flex the knee while pushing down on the knee to resist it and noting if the patient complains of pain B. Palpating deeply a point of the abdomen, located halfway between the umbilicus and the left anterior iliac crest C. Asking the patient to flex the right hip and knee to 90 degrees, then abducting the leg and noting if the patient complains of pain D. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of pain
D. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of pain
When performing a skin assessment of an adult patient, the nurse expects what finding? A. Reddened area does not blanche when gentle pressure is applied B. Indentation of the finger remains in the skin after palpation C. Flaking or scaling of the skin D. Return of skin to its original position when pinched up slightly
D. Return of skin to its original position when pinched up slightly
When inspecting a patient's abdomen, which finding does the nurse note as normal? A. Engorgement of veins around the umbilicus B. Sudden bulge at the umbilicus when coughing C. Visible peristalsis in all quadrants D. Silver-white striae extending from the umbilicus
D. Silver-white striae extending from the umbilicus
When palpating the right lobe of the patient's thyroid gland using the anterior approach, the nurse feels the tissue between which two structures? A. Sternocleidomastoid and trapezius muscles B. Trapezius muscle and the trachea C. Cricoid process and the trachea D. Sternocleidomastoid and the trachea
D. Sternocleidomastoid and the trachea
A nurse examines a patient and finds a single, firm, painless open sore with indurated borders on the vulva. The nurse correlates this finding with which disorder? A. Human papillomavirus (HPV) infection B. Herpes infection C. Gonorrhea D. Syphilis
D. Syphilis A-wart-like growths B- forms vesicles C- yellow-green vaginal discharge
How does the nurse recognize normal accommodation? A. The patient has peripheral vision of 90 degrees left and right B. The patient's eyes move up and down, side to side, and obliquely C. The right pupil constricts when a light is shown in the left pupil D. The patient's pupils dilate when looking toward a distant object
D. The patient's pupils dilate when looking toward a distant object
Which technique does a nurse use to palpate the patient's axillary lymph nodes? A. With the patient sitting, the nurse places fingers of both hands deep into the axilla, one hand on either side, and firmly pushes the axillary tissue toward the center to feel for enlarged nodes. B. With the patient lying supine with arms at the sides, the nurse uses the tips of the fingers of one hand to palpate the axilla moving from the posterior to the anterior aspect of the axilla to feel for enlarged nodes. C. With the patient lying supine with the hand behind the head of the side being assessed, the nurse uses the pads of fingers of one hand to systematically palpate the axilla using small circular motions to feel for enlarged nodes. D. With the patient sitting, the nurse places fingers of one hand deep into the axilla and firmly slides the fingers along the patient's middle, anterior, and posterior of the axilla to feel for enlarged nodes.
D. With the patient sitting, the nurse places fingers of one hand deep into the axilla and firmly slides the fingers along the patient's middle, anterior, and posterior of the axilla to feel for enlarged nodes.
