NUR 230 Final exam review
Assessment of the eyes includes select all that applies A. external structures B. visual acuity C. ocular movement D. visual field
A, B, C, D
Which are the risk factor for coronary heart disease? Select all that apply A. diabetes B. gender C. smoking D. high cholesterol
A, B, C, D
During a functional assessment of an older person's home environment, what statement or question by the nurse is most appropriate regarding common environmental hazards? A. "Do you have a relative or friend who can help to install grab bars in your shower?" B. "It would be safer to keep the lighting low in this room to avoid glare in your eyes." C. "These small rugs are ideal for preventing you from slipping on the hard floor." D. "These low toilet seats are safe because they are nearer to the ground in case of falls."
A. "Do you have a relative or friend who can help to install grab bars in your shower?"
A nurse is integrating health promotion education into the assessment of a patient's mouth, nose, and throat. What interview question is MOST likely to identify a risk factor for oral cancer? A. "Do you use tobacco, whether smoking or chewing?" B. "Do you brush and floss daily?" C. "Would you say that you're prone to getting mouth ulcers?" D. "How often do you usually go to the dentist in a year?"
A. "Do you use tobacco, whether smoking or chewing?"
A weak but palpable pulse would be documented how? A. 1+ B. 3+ C. 2+ D. 4+
A. 1+
A nurse assesses the radial pulse of a patient. Which pulse rate would the nurse document as bradycardia? A. 52 beats/minute B. 94 beats/minute C. 82 beats/minute D. 64 beats/minute
A. 52 beats/minute
A clinic nurse is admitting a teenage patient with complaints of itching and burning in his genital area. He tells you "I am sure I have a sexually transmitted infection. This will be the third one in 3 months." What action would be most appropriate with this patient? A. Assess the patient's knowledge and understanding of safe sexual practices B. Teach the patient correct use of condom to prevent pregnancy C. Provide patient with educational material on testicular cancer D. Provide samples of spermicides to patient
A. Assess the patient's knowledge and understanding of safe sexual practices
When palpating the trachea, the nurse is feeling for A. deviation (crookedness) B. lumps C. masses D. possible tumors
A. Deviation (crookedness)
A nurse performs an assessment on a 70-year-old patient. The patient's blood pressure is 140/100 mm Hg; heart rate 104 and slightly irregular; and split S2. What assessment finding can be explained by expected hemodynamic changes related to age? A. Increase in systolic blood pressure B. Decrease in diastolic blood pressure C. Increase in resting heart rate D. Irregular heart rhythm
A. Increase in systolic blood pressure
A client reports having pneumonia as a child. What area of the health history would the nurse document this? A. past history B. review of symptoms C. family health history D. history of present illness
A. Past history
A nurse assesses a patient's major risk factors for heart disease. What additional data should the nurse obtain when taking a health history? A. Smoking, hypertension, obesity, diabetes, high cholesterol B. Alcohol consumption, obesity, diabetes, stress, high cholesterol C. Family history, hypertension, stress, age D. Personality type, high cholesterol, diabetes, smoking
A. Smoking, hypertension, obesity, diabetes, high cholesterol
A nurse conducts a testicular examination on a 30-year-old man. Which finding is expected? A. Testes that feel oval and movable, slightly sensitive to compression B. Single, hard, circumscribed, movable mass, less than 1 cm under surface of testes C. Nontender subcutaneous plaques D. Scrotal area that is dry, scaly, and nodular
A. Testes that feel oval and movable, slightly sensitive to compression
Crossing the legs would be an example of what type of musculoskeletal movement? A. adduction B. pronation C. supination D. abduction
A. adduction
Which of the following nursing diagnoses is most appropriate for a patient with dysphagia? A. at risk for aspiration B. at risk for falls C. at risk for sleep deprivation D. at risk for malnutrition
A. at risk for aspiration
A patient with a long history of chronic obstructive pulmonary disease (COPD). During the assessment, what finding is the nurse most likely to observe? A. Barrel chest with A-P diameter ratio of 1:1 B. Increased tactile fremitus C. Atrophied neck and trapezius muscles D. Unequal chest expansion
A. barrel chest with A-P diameter ratio of 1:1
Loss of opacity of the lens which blocks light rays A. cataracts B. glaucoma C. macular degeneration D. blindness
A. cataracts
The skin holds information about a person's A. circulatory status B. support systems C. neurological status D. psychological wellness
A. circulatory status
Prevention and treatment of ____________ may be one of the most effective interventions aimed at reducing functional decline in an older adult. A. depression B. bladder and bowel incontinence C. visual disturbances D. hearing loss
A. depression
What are the characteristics of lymph nodes in clients with an acute infection? A. round, rubbery, and mobile B. enlarged and tender C. hard, fixed, and painless D. soft, mobile, and painless
A. enlarged and tender
Using research and clinical evidence A. evidence-based practice B. experience-based practice C. clinical-based practice D. research-based practice
A. evidence-based practice
During a clinic visit, the mother of 3-year-old states "he points to his stomach and says, it hurts so bad." Which pain assessment tool should be used when assessing a child's pain? A. Faces pain scale B. Numeric rating scale C. Brief pain inventory D. The Descriptor Scale
A. faces pain scale
The nurse leads an adolescent health information group at a community health center. The nurse knows that youths at this age are trying to find out "who they are", and which directions they want to take in school, life, and relationships. How does Erikson classify this stage? A. identity vs. role confusion B. career experimentation C. relationship testing D. adolescent rebellion
A. identity vs. role confusion
An example of acute pain includes which of the following? A. kidney stones B. arthritic pain C. fibromyalgia D. nerve damage
A. kidney stones
A patient is experiencing epistaxis. What is this? A. nose bleed B. congestion C. runny nose D. inflammation
A. nose bleed
Which of the following would the nurse do to assess the depth of a patient's respirations? A. Observe the patient's chest expansion bilaterally. B. Count the respirations for 30 seconds and multiply by 2. C. Place the patient's arm across the chest while palpating the pulse. D. Note the rise and fall of the patient's chest.
A. observe the patient's chest expansion bilaterally
"You mentioned having shortness of breath. Tell me more about that." A. open-ended question B. Reflection C. close-ended question D. facilitation
A. open-ended question
Vital signs are affected by A. pain B. hearing C. vision D. rain
A. pain
What are we assessing: PERRLA A. pupils equal B. relation C. raised D. auscultation
A. pupils equal
During percussion, the nurse knows that a low-pitched, hollow sound elicited over a lung lobe most likely results from: A. shallow breathing B. increased density of lung tissue C. decreased adipose tissue D. healthy lung tissue
A. shallow breathing
Which test assesses distant eye acuity? A. Snellen B. rosenbaum C. jaegar D. ishihara
A. snellen
It is dangerous for a cognitive change to be attributed to the normal aging process because: A. this may delay the diagnosis of an underlying disease process. B. cognitive change is not associated with aging. C. nurses are not trained properly to make these types of judgments. D. the client could be saying confusing comments to avoid detection of addictions.
A. this may delay the diagnosis of an underlying disease process.
Kids vital signs. The average vital sign of a child who is 6 to 11 yo are: HR: 75 to 118 beats per minute. RR: 18 to 25 per minute, b/p: systolic 97 to 120, diastolic 57 to 80, Temp: 98.6 F. A. true B. false
A. true
A patient is brought to the emergency department with severe shortness of breath and fever. Which method of temperature measurement would be appropriate? Select all that apply. A. Rectal B. Tympanic C. Temporal D. Oral
B & C
Adequate capillary refill should take no more than __ second(s) A. 5 second B. 2 second C. 10 second D. 1 second
B. 2 second
The nurse should use what assessment tool to assess the client's risk for skin breakdown? A. Hendrich II B. Braden Scale C. Morse Scale D. VTE prophylaxis algorithm
B. Braden scale
The school nurse is assessing a 15-year-old patient. The nurse understands that this child's current priorities will most likely reflect what developmental task? A. Becoming productive B. Developing a personal identity C. Learning new information D. Exerting influence
B. Developing a personal identity
While talking with an older adult patient, the patient states, "My son takes care of all my money. He controls the purse-strings in the house. I have little to say in how my money is spent." Further assessment reveals that the patient hasn't had his prescription medications renewed for the past two months. The nurse suspects which type of abuse? A. Physical B. Economic C. Sexual D. Psychological
B. Economic
How will the healthcare provider accurately measure a healthy child's height? A. Any age - parent may stand on scale with child if needed B. Measure the child standing in upright position starting between 2 and 3 years of age C. Always use a measuring tape D. A child should always be measured in the recumbent position
B. Measure the child standing in upright position starting between 2 and 3 years of age
After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as subjective data? A. Complains of pain in hips and legs B. Neck rotation is limited to 50 degrees C. Jaw moves laterally and protrudes and retracts easily D. No swelling or deformities on the hands
B. Neck rotation is limited to 50 degrees
While counting the apical pulse of a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? A. Refer the patient to a cardiologist for further testing. B. No further response is needed because this is an expected finding in this client. C. Talk with the patient about his intake of caffeine. D. Perform an electrocardiogram after the examination.
B. No further response is needed because this is an expected finding in this client.
A patient requests to be discharged to home instead of a rehabilitation hospital after a hip fracture. Which of the following is true about the difference between home care and hospital care? A. Physical therapy is only available in the hospital setting. B. Patients have less risk for infection in the home setting. C. Home care is more expensive than hospitalization. D. Patients have been shown to recover slower at home than in the hospital.
B. Patients have less risk for infection in the home setting.
The nurse assesses a patient with Multiple Sclerosis and finds that they have weakness and numbness in their lower extremities. What nursing problem would be identified for this patient? A. Chronic pain B. Risk for injury C. Confusion D. Risk for aspiration
B. Risk for injury
A nurse assesses a female adult patient who states that she has a urinary tract infection. The nurse notes that the patient is unkempt, wearing stained clothing, and has a strong body odor. The patient mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse identify for this patient? A. Caregiver role strain related to fatigue B. Self-care deficit related to possible homelessness C. Deficient fluid volume related to possible urinary tract infection D. Impaired skin integrity related to neurologic deficits
B. Self-care deficit related to possible homelessness
Edma is Latin for what conditions? A. constipation B. swelling C. dry skin D. none of these
B. Swelling
What would be included in an assessment of a patient's ability to perform instrumental activities of daily living? A. Dressing, toileting, and using stairs B. Taking medications, shopping, and meal preparation C. Balance, gait, and motor coordination D. Eating, bathing, and grooming
B. Taking medications, shopping, and meal preparation
The nurse is completing a client's genitourinary assessment and is preparing to assess the client's cervix. What finding would most clearly warrant referral? A. The cervix is firm on palpation. B. The cervix is immobile on palpation. C. The cervix projects 2 cm into the client's vagina. D. The cervix is smooth and pink on inspection.
B. The cervix is immobile on palpation.
The nurse is teaching parents of children of various ages how to best measure a child's temperature. The nurse instructs the parents that rectal temperature measurement is indicated in what situation? A. When a child is dehydrated B. When no other route is feasible C. When rapid temperature changes occur D. During the newborn period
B. When no other route is feasible
Health promotion for children should incorporate teaching about lifelong health. What information will the nurse include with parents and children to promote lifelong health? A. Prevention of illnesses B. All of the above C. Good nutrition D. Exercise
B. all of the above
An adult patient tells the nurse that she frequently experiences burning and itching in both eyes. The nurse should assess the patient for A. blind spots. B. allergies. C. recent trauma. D. a foreign body.
B. allergies
When assessing a patient's pulse, the nurse should also notice which of these characteristics? A. timing in the cardiac cycle B. amplitude C. pallor D. capillary refill time
B. amplitude
This is an example of A. pallor B. clubbing C. edema D. this is normal
B. clubbing
A nurse auscultating bowel sounds, does not hear any in the RLQ, what should be done next? A. listen for one minute, if none are noted document hypoactive B. continue listening in the RLQ for 5 minutes C. document the finding as normal, and move on D. call the physician right away
B. continue listening in the RLQ for 5 minutes
The nurse is preparing to examine the ears of an adult patient with an otoscope. The nurse should plan to A. use a speculum that measures 10 mm in diameter. B. firmly pull the auricle out, up and back. C. ask the patient to tilt the head slightly forward. D. release the auricle during the examination.
B. firmly pull the auricle out, up and back
How should the nurse should screen for intimate partner violence (IPV)? A. with others present B. incorporated into the routine history C. only if IPV is suspected D. only in women who are at risk
B. incorporated into the routine history
The nurse is performing an admission assessment on an older adult. What would be an expected finding? A. Positive Babinski response B. Lightheadedness C. Acute confusion D. Decreased sense of smell
B. lightheadedness
A nurse is collecting a thorough and accurate subjective history related to a client's nails. The client asks why this is necessary. How should the nurse respond to the client's question? A. Nail problems may affect a person's body image negatively B. Nail problems can be caused by an underlying systemic illness C. Abnormalities may be a sign of poor hygiene D. Local irritation can cause damage to the nail bed
B. nail problems can be caused by an underlying systemic illness
Is nasal discharge normal? A. never B. only when clear C. only when no other symptoms are present D. always
B. only when clear
Subjective data includes: A. Height B. Pain level C. B/P D. HR
B. pain level
When preparing an education session for a group of women who have been identified as postmenopausal who are at risk for osteoporosis, the nurse should include what information in the teaching? A. Increase Vitamin C in the diet B. Teach that they should stop smoking C. Minimize weight lifting exercise. D. Drink two to three glasses of wine a day
B. teaching that they should stop smoking
Deep wound due to loss of skin A. scar B. ulcer C. excoriation D. keloid
B. ulcer
What assessment finding is most likely associated with lymphedema? A. Absent pulse B. Unilateral edema C. Ulceration in the skin D. Areas of pigmentation
B. unilateral edema
A patient who works in a manufacturing plant is attending a teaching session on plant safety. What would be an important risk prevention measure to teach regarding hearing? A. Limiting loud noise exposure to 1 hour per day B. Wearing ear protection when in the work environment C. Taking a 10-minute break every 2 hours D. Cleaning ears regularly to prevent ear infections
B. wearing ear protection when in the work environment
When an otoscope examination is performed on an older adult client, the tympanic membrane may be: A. thinner than that of a younger adult. B. whiter than that of a younger adult. C. pinker than that of a younger adult. D. more mobile than that of a younger adult.
B. whiter than that of a younger adult
The nurse in a prenatal clinic is performing an assessment on a pregnant client. When it is noted that clumps of hair are missing from the client's scalp, the nurse should ask what assessment question? A. "What do you know about the problem of domestic violence?" B. "Have you ever been the victim of a crime?" C. "Do you feel safe in your home setting?" D. "Can you tell me if anyone recently attacked you?"
C. "Do you feel safe in your home setting?"
A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from prostate cancer and is concerned this will happen to him. What would be the best response by the nurse? A. "The swelling in your prostate is only temporary and will go away." B. "It would be very unusual for a man your age to have cancer of the prostate." C. "The enlargement of your prostate is caused by hormone changes and not cancer." D. "We will treat you with chemotherapy so we can control the cancer."
C. "The enlargement of your prostate is caused by hormone changes and not cancer."
The nurse tests the distant visual acuity of several patients and records the findings. Which finding indicates the patient with the poorest vision? A. 20/50 B. 20/30 C. 20/60 D. 20/40
C. 20/60
A nurse is teaching a group of parents enrolled in a child-rearing class. What action will the nurse emphasize to the parents that will help their school-age child achieve the psychosocial task of industry and avoid inferiority? A. Increase socialization B. Encourage competition C. Acknowledge accomplishments D. Allow independence
C. Acknowledge accomplishments
The nurse is meeting the parents of an ill child for the first time and is preparing to perform the health interview. In addition to gathering health data, what additional goal will the nurse prioritize during this interaction? A. Emphasize the importance of adherence to treatment B. Identify the family's socioeconomic status C. Foster trust with the child's parents D. Gauge the parents' own levels of health
C. Foster trust with the child's parents
What is the optimal patient position when assisting with a female genitourinary exam? A. Sims' position B. Trendelinburg C. Lithotomy D. Prone
C. Lithotomy
In assessing a patient, the nurse notices that they have a masked facial expression, shuffling gate, and tremors in the hands. What neurological problem would the nurse suspect? A. Multiple Sclerosis B. Stroke C. Parkinson's Disease D. Bell's Palsy
C. Parkinson's Disease
When interviewing an adolescent, what health issue would be least appropriate to discuss with the patient while a parent is present? A. Nutrition B. Immunizations C. Sexuality D. Sleep patterns
C. Sexuality
The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability? A. Press down on one of the client's nail beds. B. Gently shake the client's right shoulder and then his left shoulder. C. Speak to the client clearly from a close distance. D. Rub the client's sternum with the knuckles.
C. Speak to the client clearly from a close distance.
The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further. A. acromioclavicular joint B. sternoclavicular joint C. temporomandibular joint D. interphalangeal joint
C. Temporomandibular joint
The older adult with new-onset delirium will usually have: A. vertigo. B. violent behavior. C. a short attention span. D. difficulty hearing.
C. a short attention span.
The nurse asks the patient if they can perform routine hygiene. What is the nurse assessing? A. SPICES B. get up and go test C. activities of daily living D. range of motion exercise
C. activities of daily living
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? A. Breathing, sleep, pain B. Sleep, pain, breathing C. Breathing, pain, sleep D. Sleep, breathing, pain
C. breathing, pain, sleep
A nurse performs a comprehensive assessment on a client. Which of the following components is included only in a comprehensive assessment? A. Circulatory assessment B. Assessment of the airway C. Complete health history D. Disability assessment
C. complete health history
When assessing a patient's carotid pulses, which of the following would be contraindicated? A. asking the client to keep the head erect B. performing the exam while the patient is seated C. compressing the arteries bilaterally D. asking the patient to swallow water
C. compressing the arteries bilaterally
Signs of caregiver burnout include: A. using an adult day care facility. B. going to church every week. C. headaches and epigastric pain. D. weight gain.
C. headaches and epigastric pain.
What condition does not contribute to the formation of ulcers in the lower extremities? A. diminished sensation in pressure points B. venous insufficiency C. hypertension D. arterial insufficiency
C. hypertension
A patient asks why a health assessment needs to be done. What should the nurse respond to this patient? A. "It is used to validate the findings from the health care provider's examination." B. "It serves as a tool to evaluate care provided." C. "It determines your health status, risk factors and educational needs to develop a plan of care." D. "It reduces the work load for the health care provider"
C. it determines your health status, risk factors and educational needs to develop a plan care
Which statement is true related to older adult considerations with the musculoskeletal system? A. Osteoporosis becomes less common. B. Bones become more dense. C. Kyphosis is common with aging. D. Older adults are at lower risk for falls.
C. kyphosis is common with aging
The nurse feels a small mass in the neck of a patient. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling? A. Muscle B. Cancer C. Lymph node D. Deep scar
C. lymph node
BMI over 30 A. overweight B. nutrient density C. obese D. body mass index
C. obese
The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. When educating the patient, on what topic will the nurse focus education? A. Risks of fungal infections B. Management of dry skin C. Risks of cancer D. Susceptibility to bruising
C. risks of cancer
Nurses working with patients in pain need to recognize and avoid common misconceptions about pain. In regard to the pain experience, which of the following is correct? A. Chronic pain is mostly psychological in nature B. The amount of tissue damage is accurately reflected in the degree of pain perceived C. The patient's self-report of pain is the most reliable indicator of pain experience D. Regular use of analgesics leads to drug addiction
C. the patient's self-report of pain is the most reliable indicator of pain experience
A nurse assesses a patient's capillary refill in the upper extremities and finds it to be less than 2 seconds. What action should the nurse take based on this assessment finding? A. Refer the patient for medical follow-up. B. Recheck in 5 minutes after elevating the arm. C. This finding is expected and should be documented. D. Reassess after applying warm compresses.
C. this finding is expected and should be documented
In performing a breast examination, why does the nurse know that it is especially important to examine the upper outer quadrant of the breast? A. This area is more prone to injury and calcifications than other locations in the breast. B. It is the largest quadrant of the breast. C. This is the location of most breast tumors. D. It is where most of the suspensory ligaments attach.
C. this is the location of most breast tumors
The Katz Index of Independence in ADL would measure the functional ability to: A. clean the house and take out the garbage. B. do laundry and put away the clothes. C. wash the face and hands and comb hair. D. pay the electric and telephone bill.
C. wash the face and hands and comb hair.
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function, the nurse would expect that he: A. may show evidence of some clouding of his level of consciousness. B. may display some disruption in thought content. C. will be oriented to place and person but may not be certain of the date. D. will state, "I am so relieved to be out of intensive care."
C. will be oriented to place and person but may not be certain of the date.
Which patient population has the highest incidents of domestic violence? A. Men B. Older adult C. Women D. Children
C. women
The nurse is performing a physical assessment of the abdomen. In what order will the nurse perform the assessment? A. percussion B. palpation C. inspection D. Ausculatation
C>D>A>B inspection> auscultation> percussion> palpation
A patient is being seen in the clinic for a routine physical exam and states "My doctor order a PSA test, what is this test for?" What is the most appropriate response by the nurse? A. "The test is done on all males starting at age 35." B. "It is a test for colon cancer." C. "Don't worry we do this test on everyone just to make sure your rectal area is free of disease." D. "It is a test for prostate cancer and is done on males after age 50."
D. "It is a test for prostate cancer and is done on males after age 50."
A parent tells the nurse, "I am worried about my 13-year-old son. He hasn't started puberty yet and my daughter did when she was 11 years old." What response by the nurse would be most appropriate? A. "Puberty normally occurs at the same time in siblings." B. "Your son needs to have a medical evaluation." C. "Your daughter experienced puberty very early." D. "The onset of puberty is normally earlier in girls."
D. "The onset of puberty is normally earlier in girls."
Which statement is best for the nurse to use when preparing to administer the Abuse Assessment Screen? A. "We are required to complete the section on the admission form." B. "We need to talk about whether you feel you have been abused." C. "We are asking these questions because we suspect that you are being abused." D. "We ask the following questions because domestic violence is so common in our society."
D. "We ask the following questions because domestic violence is so common in our society."
The nurse is preparing to assess the remote memory of a client who has a diagnosis of early-stage Alzheimer's disease. Which question would be most appropriate for the nurse to use? A. "How are an apple and an orange the same?" B. "Can you tell me what you have eaten in the last 24 hours?" C. "What did you do last evening?" D. "When did you get your first job?"
D. "When did you get your first job?"
During the health history of a patient, the nurse notices weakness on one side of the face. Which cranial nerve would the nurse suspect is being affected? A. CN I B. CN II C. CN IX D. CN VII
D. CN VII
Which area of the brain that is related to balance? A. thalamus B. extrapyramidal tract C. brainstem D. cerebellum
D. Cerebellum
Which of the following would be an indication that an older adult should stop driving a vehicle? A. A pacemaker placed 2 months ago for complete heart block B. Difficulty walking and getting in and out of the vehicle C. Taking insulin to control type 2 diabetes mellitus D. Difficulty checking over the shoulder when backing up or changing lanes
D. Difficulty checking over the shoulder when backing up or changing lanes
Which of these individuals would the nurse consider at highest risk for a suicide attempt? A. Man who jokes about death B. Adolescent who broke up with boyfriend and states that she would like to kill herself C. Woman reporting a feeling of major depression D. Elderly man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun
D. Elderly man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A. Third left intercostal space at the midclavicular line. B. Fourth left intercostal space at the sternal border C. Fourth left intercostal space at the anterior axillary line. D. Fifth left intercostal space at the midclavicular line.
D. Fifth left intercostal space at the midclavicular line.
A patient is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The patient also has a history of vomiting with a headache. What type of headache could these findings indicate? A. Cluster B. Tension C. Benign D. Migraine
D. Migraine
A patient is admitted with non-healing leg wounds & reddish blue lower extremities. This is indicative of A. PAD B. CAD C. HF D. PVD
D. PVD
When the nurse is examining a male client's genitalia, the client experiences an erection. What would be most appropriate for the nurse to do? A. Stop the exam and leave the room for a few minutes. B. Ask the client whether continuing the exam will embarrass him. C. Remain silent but continue the examination. D. Reassure the client that this is not unusual.
D. Reassure the client that this is not unusual.
When preparing to examine a 6-year-old, what approach is best for the nurse to take when beginning the examination? A. Ask the child if it is ok for the nurse to look in the ears B. Tell the child that the examination will not hurt C. Ask the parent if the child has had any pain D. Show the child the equipment to be used
D. Show the child the equipment to be used
Which of the following is the correct method for the nurse to use when progressing from one auscultatory site on the thorax to another? A. Interspace-by-interspace B. Posterior-to-anterior C. Top-to-bottom D. Side-to-side
D. Side-to-side
What is the preferred position in which to place a healthy adult male patient to examine the rectum and prostate? A. Right lateral Sims position. B. Supine position with hips and legs flexed and feet positioned on the examining table. C. Modified knee-chest position with the patient prone and knees flexed under hips. D. Standing and leaning over the examination table or bed with chest and shoulders resting on the table/bed.
D. Standing and leaning over the examination table or bed with chest and shoulders resting on the table/bed.
The nurse assesses the Glasgow coma scale at 14. How would the nurse interpret this? A. deep coma B. obtunded C. coma D. alert and oriented
D. alert and oriented
When assessing the nail, the nurse looks for A. shape B. texture C. color D. all of the above
D. all of the above
What child is at most risk of recurrent otitis media? A. A 6-month-old infant who has a sibling who had tubes inserted at 3 years of age. B. A 2-year-old child who has had two ear infections in the past 6 months. C. An 18-month-old infant who lives with a smoker. D. An 18-month-old infant who has had three episodes of ear infections in a 5-month period.
D. an 18mo infant who has had three episodes of ear infections in a 5-month period
The nurse documents a 2+ radial pulse. What assessment data indicated this result? A.absent (unable to palpate) pulse B. bounding pulse C. diminished pulse D. brisk, expected (normal) pulse
D. brisk, expected (normal) pulse
Altered cognition in older adults is commonly attributed to: A. medication side effects. B. the normal aging process. C. an infection or injury. D. dementia, delirium, or depression.
D. dementia, delirium, or depression.
A positive response to which question would suggest a migraine headache? A. do they occur after you have been tense or anxious? B. when you consume alcohol, do you get a headache? C. do you have any eye symptoms, such as tearing? D. do you have visual changes before the headache?
D. do you visual changes before the headache?
S/S of dehydration A. smooth mucous membranes and lips B. white patches on mucous membranes C. pale lips and gums D. dry mucous membranes and cracked lips
D. dry mucous membranes and cracked lips
A nurse is admitting a 30-year-old female client and recognizes the need to screen the client for abuse. What would the nurse do next? A. Perform a physical assessment. B. Obtain informed consent. C. Teach the client signs of abuse. D. Ensure a private setting.
D. ensure a private setting
When auscultating the lungs the nurse hears high-pitched popping sounds. How will this be documented? A. course crackles B. sonorous wheeze C. sibilant wheeze D. fine crackles
D. fine crackles
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? A. Pain sensation behind eyes B. No sensation C. Pain during palpation D. Firm pressure
D. firm pressure
A female is scheduled for an annual gynecologic examination. The nurse should begin the interview with: A. sexual history because it will build rapport. B. urinary system history because there may be problems in this area. C. obstetric history because it is the most important information. D. menstrual history because it is generally nonthreatening.
D. menstrual history because it is generally nonthreatening.
A nurse educator is preparing education on breast cancer for a group of women. What symptoms will the nurse include in the teaching that may occur with breast cancer? A. Breast fullness and pain B. One breast that is slightly larger C. Redness and warmth with smooth texture D. Orange peel-like appearance
D. orange peel-like appearance
A 52-year-old female patient states "when I sneeze or cough, I wet myself a little. I am really worried that something may be wrong." What problem would the nurse suspect the patient is experiencing? A. hematuria. B. urge incontinence. C. dysuria. D. stress incontinence.
D. stress incontinence
The mother of a 10yo boy asks the nurse about puberty. The nurse should reply by saying A. puberty usually begins around 15 years of age B. the penis size doesn't increase until 16 years of age C. the development of pubic hair is first D. the first sign of puberty is an enlargement of the testes
D. the first sign of puberty is an enlargement of the testes
The client complains of ringing, crackling or buzzing in the ear. What is the term for this? A. tympanic B. vertigo C. otitis media D. tinnitus
D. tinnitus
What skin assessment will the nurse implement to determine the presence of dehydration in a client? A. Temperature B. Texture C. Thickness D. Turgor
D. turgor
What would the nurse ask the patient to do in order to assess the cerebellar system? A. walk across the room B. open mouth wide and say "aahh" C. stick out tongue and move from side to side D. turn the head side-to-side against resistance
D. turn the head side-to-side against resistance
