Nursing Health Assessment Exam #2

Which of the following is an example of inspection? A.Heart rate and rhythm regular B.Lungs clear C.Abdomen tympanic D.Skin pink

D. Skin pink.

All of the following skin lesions may be papular except A.warts. B.acne. C.nevi. D.herpes zoster.

D. herpes zoster

The correct position in which to place a healthy adult male client to examine the rectum and prostate is A.the left lateral Sims position with right knee flexed and left leg extended. B.the supine position with hips and legs flexed and feet positioned on the examining table. C.the modified knee-chest position with the patient prone and knees flexed under hips. D.standing and leaning over the examination table with chest and shoulders resting on the table.

D.standing and leaning over the examination table with chest and shoulders resting on the table.

When the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first? A.Chest soreness B.Dyspnea C.Cough D.Sputum

B. dyspnea

A patient says that she is having throbbing pain that she rates as 6 on a 10-point scale. This is referred to as A. subjective primary data. B. subjective secondary data. C. objective primary data. D. objective secondary data.

A. subjective primary data

Select all actions that are acceptable under the HIPAA Privacy Rule. A.Communicate report with the next nurse during change of shift. B.Communicate with the primary care provider about a patient's change in assessment. C.Consult in the hall with the instructor about the patient's abnormal findings. D.Describe patient assessment findings to a colleague in the cafeteria.

A. Communicate report with the next nurse during change of shift; B. Communicate with the primary provider about a patient's change in assessment.

A fair-skinned, blonde, 18-year-old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? (Select all that apply) A.Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer. B.Apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure. C.Avoid sun exposure between 10 am and 4 pm to reduce UVA and UVB exposure. D.A mild sunburn is acceptable in a fair-skinned blonde person.

A,B,C

Symptoms and assessment for alcohol withdrawal are measured by which of the following assessments? Select all that apply. A.Observing for tremors with arms extended and fingers spread apart B.Observing for paroxysmal sweats C.Observing for agitation D.Asking, "Are you hearing things you know are not there?" E.Asking, "Are you seeing anything that is disturbing to you?" F.Assessing orientation to person, place, and time G.Assessing developmental stage

A,B,C,D,E,F

Which actions will result in an inaccurate BP reading? Select all that apply A. Obtaining BP immediately after the patient has entered the room B. Using a BP cuff with a bladder length with is 80% of the arm circumference C. Asking the patient to hold out his or her arm above heart level D. Pumping the cuff 10mmHg above the palpated systolic BP

A-obtaining a BP immediately after the patient has entered the room. C-asking the patient to hold out his/her arm above heart level. D-pumping the cuff 10mmHg above the palpated systolic BP

To assess self-perception, the nurse asks A. "How would you describe yourself?" B. "Are you having difficulty handling any family problems?" C. "What gives you hope when times are troubled?" D. "How do you usually deal with stress? Is it effective?"

A. "How would you describe yourself?"

Which question(s) should you ask to assess medication use in the older adult living in the community? Select all that apply. A."What medications are you taking?" B."What is the schedule for your medications?" C."Tell me why you are taking all of your medications." D."What is the dose of the medication that you take?"

A. "What medications are you taking?"; B. "What is the schedule for your medications?"; C. "Tell me why you are taking all of your medications."; D. "What is the dose of the medication that you take?" (All of the above)

Children are usually brought for health care visits by a parent. At about what age should you begin to question the child, rather than the parent, regarding presenting symptoms? A.5 years of age B.7 years of age C.9 years of age D.11 years of age

A. 5 years of age

Which of the following patients should the nurse see first? A.A patient with unilateral changes in vision B.A patient with ectropion of the lower lid C.A patient with presbyopia D.A patient with senile ptosis

A. A patient with unilateral changes in vision.

When assessing a child, the nurse makes the following adaptation to the usual techniques: A.A pediatric stethoscope is used for better contact. B.The child is seated away from the parent. C.The room is full of toys for play. D.The child is undressed, including the diaper.

A. A pediatric stethoscope is used for better contact.

The patient has pain of a short duration with an identifiable cause. This is referred to as A. Acute pain B. Chronic pain C. Neuropathic pain D. Complex pain

A. Acute pain

A patient reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should you omit? A. Adduction B. Hyperextension C. Extension D. Circumduction

A. Adduction

Standard precautions A.are used on every patient because it is not always known whether a patient is infected. B.state that hand gel is used for infection with Clostridium difficile. C.include the use of gowns, gloves, and masks with all patients. D.recognize that transmission-based precautions are common.

A. Are used on every patient because it is not always known whether a patient is infected.

A 70-year-old man presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition? A.Benign prostatic hypertrophy (BPH) B.Prostatitis C.Testicular cancer D.Phimosis

A. Benign prostatic hypertrophy (BPH)

Primary nutrients essential for optimal body function include: A. carbohydrates, proteins, and fats B. folate, vitamin B12, and iron C. vitamins A, D, E, and K D. iron, zinc, and calcium

A. Carbohydrates, proteins, and fats

A Pap smear is recommended to screen for what condition? A.Cervical cancer B.Ovarian cancer C.Endometrial cancer D.Vaginal cancer

A. Cervical cancer

With which of the following types of patients is the nurse most likely to use the FACES pain scale? A. Children B. Patients with dementia C. Older adults D. Unconscious patients

A. Children

The nurse's response to Emily's length, which is 66cm (26in) now at age 12 months and was 51cm (20in) at birth, is to be: A. Concerned because Emily should have grown 25 to 30 cm (10 to 12 in) by now B. Unconcerned because Emily should have grown 15 cm (6 in) by now C. Concerned because Emily should have doubled her birth length by now D. Unconcerned because Emily should have grown 7.6 to 10 cm (3 to 4 in) by now

A. Concerned because Emily should have grown 25 to 30 cm (10 to 12 in) by now

The patient with a head injury and increasing ICP is likely to have which assessment findings? A. Decreased LOC and sluggish pupil B. Left sided weakness and facial droop C. Right ptosis and right-sided loss of vision D. dilated left pupil and receptive aphasia

A. Decreased LOC and sluggish pupil

Which of the following findings during the general survey may indicate a change in mental status? Select all that apply A. Disheveled appearance B. Rapid speech C. Lethargy D. Asymmetrical movements

A. Disheveled appearance; B. Rapid speech; C. Lethargy

Select all of the documentation errors that are potentially high risk. A.Failure to document completely B.Inadequate admission assessment C.Charting in advance D.Bunch charting at the end of shift

A. Failure to document completely; B. Inadequate admission assessment; C. Charting in advance; D. Bunch charting at the end of shift.

The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing A. for a pulse deficit. B. the carotid pulse C. for diminished peripheral circulation D. the brachial pulse

A. For a pulse deficit

The nurse provides teaching about smoking cessation to a 20-year-old man. The nurse assesses that the patient is concerned because his father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient? A. Health belief model B. Diagnostic reasoning model C. Cultural competence model D. Body systems model

A. Health belief model

Which organs or body areas does the nurse auscultate as part of the admitting assessment? A.Heart, lungs, and abdomen B.Kidneys, bladder, and ureters C.Abdomen, flank, and groin D.Neck, jaw, and clavicle

A. Heart, lungs, and abdomen.

Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider? A. Height, weight, and vital signs. B. Active and passive ROM. C. History of current complaints. D. Muscle Strength.

A. Height, weight, and vital signs.

A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? A.Murphy sign B.Psoas sign C.Rovsing sign D.Obturator sign

A. a murphy sign

Which of the following are advantages of the electronic medical record? Select all that apply. A.Nurses can enter data by checking boxes and adding free full text. B.It is economical and easy to learn and implement. C.It allows primary care providers to directly order into the computer. D.It cannot be used as a legal document in case of a lawsuit.

A. Nurses can enter data by checking boxes and adding free full text.

Earl is healthy and vigorous at 68 years. Which of the following is a concern as he ages? Select all that apply. A. Nutritional changes B. Mobility impairments affecting activities of daily living (ADLs) C. Fall risk D. Polypharmacy

A. Nutritional changes B. Mobility impairments affecting activities of daily living (ADLs) C. Fall risk D. Polypharmacy

The nurse gathers subjective data related to the history of the present problem. The following items are included: A.Onset, location, duration, character, aggravating/associated factors, relieving factors, temporal factors, severity B.Asymmetry, borders, color, diameter C.Heart rate, respiratory effort, response, color D.Eye opening, verbal response, motor response

A. Onset, location, duration, character, aggravating/associated factors, relieving factors, temporal factors, severity

A 50-year-old patient is seen in the clinic for an annual physical examination and screening. The patient has no known health problems. This type of care is referred to as A.primary prevention. B.promotion prevention. C.tertiary prevention. D.healthy prevention.

A. Primary prevention

A patient who has a BMI of 14. Which nursing intervention is indicated? A. Provide additional high protein and calorie shakes B. Reduce total fat and calorie intake C. Increase the intake of green leafy vegetables D. Eat complete meals twice a day

A. Provide additional high protein and calorie shakes

A patient develops a sudden onset of acute chest pain. In addition to a complete description of the symptoms, what objective assessment is a priority? A.Pulse, blood pressure, peripheral pulses B.Heart sounds, rate, and rhythm C.Circulation, sensation, and movement D.Murmurs, rubs, and gallops

A. Pulse, blood pressure, peripheral pulse

When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is A.S1 greater than S2. B.S1 is equal to S2. C.S2 greater than S1. D.No S1 is heard

A. S1 greater than S2

The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heard best at the apex. Which of the following does the nurse suspect? A.S3 gallop B.S4 gallop C.Systolic ejection click D.Split S2

A. S3 gallop

The nurse is assessing a 2-month-old infant whose mother brought her to the emergency department because the baby wasn't eating well and she "just looks sick." Which of the following assessment findings is most worrisome? A.Stiff neck with an arched back B.Circumoral cyanosis noted when crying C.PMI not palpable, anterior fontanel bulges slightly when crying D.Temperature 36.4°C (97.5°F), heart rate (HR) 160 beats/min, respiratory rate (RR) 38 breaths/min

A. Stiff neck with an arched back

An unconscious 22 year old man arrives at the hospital after experimenting with hallucinogenic substances. His vitals are temperature 37.2 C, orally; pulse 142 beats/min; respirations 20 breaths/min; BP 100/64mmHg. The patient is experiencing A. Tachycardia B. Eupnea C. Auscultatory gap D. Asystole

A. Tachycardia

A young male presents for a sports physical examination. In addition to examining for hernias, it would be appropriate for you to do which of the following? A.Teach testicular self-examination. B.Evaluate for urinary retention. C.Examine for prostate cancer. D.Draw blood to measure prostatic surface antigen.

A. Teach testicular self-examination.

A 20-year-old male patient presents with scrotal pain. A suspected diagnosis that requires immediate referral is A.testicular torsion. B.hydrocele. C.epididymitis. D.inguinal hernia.

A. Testicular torsion

The nurse assesses for geriatric syndromes, which are A.the interaction of multiple diagnoses that contribute to problems in the older adult. B.the exacerbation of chronic conditions, such as congestive heart failure or chronic obstructive pulmonary disease. C.conditions in which older adults may not mount an immune response. D.decreases in growth hormones and steroids that reduce functional status.

A. The interaction of multiple diagnoses that contribute to problems in the older adult.

A nurse is working with a new patient, doing a standard assessment. To establish rapport, the nurse would use which of the following statements? A. "These are questions that I ask all my patients" B. "Don't worry because we are used to working with patients" C. "We're here because we want to help people with mental health issues" D. "These questions are silly, but I have to ask them"

A. These are questions that I ask all my patients.

Which of the following symptoms is NOT an indicator of preeclampsia? A.Uncontrolled vomiting B.Headache C.Epigastric pain D.Hyperreflexia

A. Uncontrolled vomiting

All formats of progress notes A.use the nursing process in some form to show nursing thinking. B.identify the patient outcomes or goals to evaluate. C.include head-to-toe assessment data for completeness. D.have a section for evaluation of care so that nurses may revise interventions.

A. Use the nursing process in some form to show nursing thinking.

The nurse is most likely to assess pain using the McGill Pain Questionnaire to collect which data? A. Verbal description B. Alleviating factors C. Functional status goal D. Pain goal

A. Verbal description

Which of the following are nutritional cardiac risk factors? Select all that apply: A. Waist circumference of >40in. in men B. Waist circumference of >35in. in women C. A waist-to-hip ratio less than or equal to 1.0 D. Significant unintentional weight loss of 10% or more in 180 days

A. Waist circumference of >40in. in men B. Waist circumference of >35in. in women

The nurse palpates a fine, round, mobile, nontender nodule and suspects that it is A.a fibroadenoma. B.a cyst. C.a fibrocystic breast change. D.breast cancer.

A. a fibroadenoma

The nurse knows that the floor of the mouth is highly vascular and therefore a good location for which of the following? A.Absorption of sublingual medications B.Identification of malignancy in the pharyngeal fossa C.Infection with streptococcus D.Aspiration, even if the gag reflex is present

A. absorption of sublingual medications

Peau d'orange appearance is highly suggestive of which of the following? A.Breast cancer B.Gynecomastia C.Papillomas D.Colostrum

A. breast cancer

A 45-year-old man has been admitted to the hospital with suspicion of PE. Which of the following symptoms should the nurse report to the primary health practitioner immediately? A.Chest pain B.Shortness of breath C.Respirations 20 breaths/min D.Productive cough

A. chest pain

Which of the following cultural variables best represent Leininger's Cultural Care Diversity Model? A.Communication, space, social, time, environment, and biology. B.Cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. C.Age, gender, nationality, ethnicity, occupation, immigration status. D.Cultural values, religion, personal philosophy of life, and spiritual beliefs, educational background.

A. communication, space, social, time, environment, and biology.

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next? A.Document this finding as normal. B.Tell the patient that this finding is unexpected. C.Report to the physician a suspicion of a slow-growing goiter. D.Look for signs of hypothyroidism.

A. document this finding as normal

2.A patient is anxious, dyspneic, and pale and uses accessory muscles to breathe. Vital signs are temperature 37°C (98.6°F), pulse 126 beats/min, respirations 40 breaths/min, and BP 122/74 mm Hg. The type of assessment that the nurse would perform is a(n) A.emergent assessment. B.general survey. C.health history. D.objective assessment.

A. emergent assessment

The nurse conducts the health history based on the patient's responses to the medical diagnosis. This type of framework is based on the A. functional framework. B. objective framework. C. coordinator framework. D. collaborative framework.

A. functional framework

The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following? A.Grade III systolic murmur B.Grade I systolic murmur C.Grade V diastolic murmur D.Grade II diastolic murmur

A. grade III systolic murmur

During routine physical examination of a 20-year-old woman, the nurse notes a septal perforation. This finding may be significant for which of the following causes? A.Illicit drug use B.Nose picking C.Nasal trauma D.Bifid uvula

A. illicit drug use

A 62-year-old woman comes to the clinic with an exacerbation of asthma. Which of the following findings indicate worsening status of her asthma? A.Increased wheezing B.Sustained rhonchi C.Decreased respirations D.Oxygen saturation 94%

A. increased wheezing

During history taking, a patient reports cramping in his calf when walking a few blocks. He states that it goes away when he sits down for a few minutes. How would the nurse document this symptom? A.Intermittent claudication B.Rest pain C.Poikilothermia D.Venous stasis

A. intermittent claudication

Which of the following statements describes the cardiovascular system most accurately? A.It is a double pump circulating blood out to the lungs and body. B.It has a heart with six chambers, great vessels, and valves. C.It includes concepts of precontractility, postcontractility, and load. D.It functions with a conduction system that starts in the ventricles.

A. it is a double pump circulating blood out of the lungs and body.

A 26 year old man was in a motor vehicle accident and suffered complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the: A. legs B. abdomen C. chest D. arms

A. legs

When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? A.Liver B.Spleen C.Sigmoid colon D.Kidney

A. liver

Amber and Manuel Carr need to be taught that 2-month-old Emily: A. needs auditory, visual, tactile, vestibular, and gustatory stimuli each day in short periods when she is awake B. will benefit from as much attention as possible C. needs to have stimuli limited to basic needs when she is seeking get attention D. will benefit from long periods of rest and sleep to allow the brain to develop

A. needs auditory, visual, tactile, vestibular, and gustatory stimuli each day in short periods when she is awake

While evaluating the inguinal lymph nodes of a patient, the nurse palpates a 1-cm (about ½-in.) soft and freely movable node. What action should the nurse take next? A.Nothing—this finding is normal. B.Refer this patient to a specialist. C.Immediately check the patient's dorsalis pedis pulse. D.Refer the patient for immediate management of a life-threatening condition.

A. nothing this finding is normal

The purpose of health assessment is to A. obtain subjective and objective data. B. intervene to correct difficulties. C. outline appropriate care. D. determine whether interventions are effective.

A. obtain subjective and objective data

Nurses belong to the ANA as part of their A. ongoing professional responsibility. B. role as manager of care. C. wellness promotion for patients. D. cultural education activities.

A. ongoing professional responsibility

A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion? A.Patch B.Plaque C.Papule D.Macule

A. patch

Which of the following represents the nurse's documentation of a patient with normal mood? A.Pleasant or appropriate to situation B.Grandiose or strongly confident C.Fearful but mildly humble and meek D.Sad and tearful during conversation

A. pleasant or appropriate to situation

The lymph nodes that lie in front of the mastoid bone are the A.preauricular nodes. B.occipital nodes. C.superficial cervical nodes. D.supraclavicular nodes.

A. preauricular node

While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action? A.Recognize that it is not common to palpate lymph nodes in this region and they must be carefully evaluated. B.Recognize that enlarged lymph nodes in this area indicate sinus inflammation. C.Recognize that this is a common area for lymph nodes to be enlarged with minor infections. D.Recognize that a palpable lymph node in this region is always indicative of malignancy.

A. recognize that it is not common to palpate lymph nodes in this region and they must be carefully evaluated.

A 24-year-old patient reports an itchy red rash under her breasts. Examination reveals large, reddened, moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions? A.Satellite B.Discrete C.Confluent D.Zosteriform

A. satellite

When assessing a patient with atelectasis, what assessment findings are expected? Choose all that apply. A.Shortness of breath B.Decreased breath sounds C.Decreased oxygen saturation D.Increased tactile fremitus E.Hyperresonance

A. shortness of breath

Even if daily prayers or other religious practices are not a part of a patient's life routine, they often take a central position during life transitions, such as the loss of a loved one, an accident, or serious illness. A related nursing diagnosis might be A.spiritual distress. B.impaired social interaction. C.readiness for enhanced spiritual well-being. D.social isolation.

A. spiritual distress

Gynecomastia may occur in an older male secondary to A.testosterone deficiency. B.lymphatic engorgement. C.trauma. D.decreased activity level.

A. testosterone deficiency

An 83-year-old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation? A.Thinning of the skin B.Increased skin turgor C.Hypopigmented flat macules and patches over sun-exposed areas D.Multiple purplish bruises on the arms and legs

A. thinning of the skin

Risk factors for nose, sinus, mouth, and throat problems include A.topical decongestant use, smoking, and allergies. B.smoking, allergies, and high blood cholesterol. C.allergies, high blood cholesterol, and topical decongestant use. D.high blood cholesterol, topical decongestant use, and smoking.

A. topical decongestant use, smoking, and allergies.

The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking A. uses subjective data to analyze findings and intervene. B. documents and communicates data using appropriate medical terminologies. C. individualizes health assessment considering the age, gender, and culture of the patient. D. uses assessment findings to identify medical and nursing diagnoses.

A. uses subjective data to analyze findings and intervene

A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. Which of the following infectious illnesses does the nurse suspect? A.Varicella B.Measles C.Roseola D.Herpes simplex

A. varicella

Acute airway obstruction is a situation that A.should be B.reassessed during the next visit. C.evaluated within 8 hours. D.further assessed thoroughly. A.quickly assessed and treated.

AA. quickly assessed and treated

Jasmyn, who has just has her second birthday, comes to the well-child clinic for an assessment. The nurse reviews her records and discovers that Jasmyn weight 3.1 kg (7 lb) at birth. Today, the nurse expects that Jasmyn's weight should be: A. 9.5 kg (21 lb) B. 12.7 kg (28 lb) C. 15.9 kg (35 lb) D. 19 kg (42 lb)

B. 12.7 kg (28 lb)

A normal fetal heart rate as auscultated with a Doppler sonometer is A.90 beats/min. B.120 beats/min. C.100 beats/min. D.180 beats/min.

B. 120 beats/ min

You evaluate all the following children one morning in the clinic. Which should you refer for further assessment? A.A 6-week-old boy whose parents recently immigrated from Thailand; his head lags when pulled up by his arms; he has several dark spots that look like bruises on his lower back and buttocks. B.A 4-week-old African American girl whose liver margins are barely palpable along the right costal margin; her kidneys are easily palpable: her ears look "funny." C.A 4-month-old Caucasian boy with loud breath sounds throughout the lung fields; auscultation of the heart reveals a split S2. D.A 9-month-old Latina who is fussy; her tympanic membrane is pearly gray and moves during pneumatic otoscopy.

B. A 4-week-old African American girl whose liver margins are barely palpable along the right costal margin; her kidneys are easily palpable: her ears look "funny."

Which of the following patients is at highest risk for osteoporosis? A. A young man, weight-lifter, who drinks beer three times a week, with a stable job. B. A middle-aged woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times a week. C. A woman who works as a vice-president, takes a shot of vodka six times a week, and exercises regularly. D. A retired man , non-smoker, who drinks alcohol socially.

B. A middle-aged woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times a week.

An auscultatory gap is defined as.. A. a drop in the SBP of 15 mm Hg or more with position change B. A period of silence heard between Korotkoff sounds C. the difference between the apical and radial pulse D. SBP minus the DBP

B. A period of silence heard between Korotkoff sounds

Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres? A. an enlarging pupil that is sluggishly reactive to light B. altered mentation C. widening pulse pressure with bradycardia D. reflex posturing of extremities

B. Altered mentation

The nurse assesses the following vital signs in a 78-year-old man: temperature 36.6 C, temporal; pulse 72 beats/min, regular, 2+; respirations 18 breaths/min, regular, no use of accessory muscles; BP 142/92 mmHg. Which of the findings is abnormal? A. Pulse B. BP C. Respirations D. Temperature

B. BP

The ABCDEs of melanoma identification do not include A.Asymmetry: one half does not match the other half. B.Birthmark: café au lait spot that does not fade. C.Color: pigmentation is not uniform; there may be shades of tan, brown, and black as well as red, white, and blue. D.Diameter: greater than 6 mm. E.Evolving: any change in size, shape, color, elevation—or any new symptom such as bleeding, itching, or crusting.

B. Birthmark: cafe au last spot that does not fade.

Which of the following tools would a nurse use to perform a multidimensional pain assessment? A. Visual analogue scale B. Brief pain inventory C. Numeric pain intensity D. Verbal descriptor

B. Brief pain inventory

Auscultation is one of the most important components of which body systems? A.Reproductive, neurological, integumentary B.Cardiovascular, pulmonary, gastrointestinal C.Pulmonary, gastrointestinal, neurological D.Gastrointestinal, neurological, reproductive

B. Cardio, pulmonary, gI

Which of the following organisms is associated with salpingitis? A.Trichinella spiralis B.Chlamydia trachomatis C.Candida albicans D.Condyloma acuminatum

B. Chlamydia trachomatis

A patient reports pain, depression, and insomnia. The nurse observes a masklike facial expression and frequent position changes. Which of the following is the nurse most likely to use to describe the patients findings? A. Acute pain B. Chronic pain C. Neuropathic pain D. Chronic regional pain syndrome

B. Chronic pain

The nurse is taking a menstrual history. What would be an appropriate question to ask? A.Do you have any history of cancer in your family? B.Do you ever skip periods? C.Do you use condoms during intercourse? D.How many sexual partners have you had?

B. Do you ever skip periods?

Which factor places an infant at greater risk than an adult for developing otitis media? A. Introduction of solid foods B. Eustachian tubes that are more horizontal (flat) than vertical and wide C. Immature cardiac sphincter D. Feeding in a semi-Fowler position

B. Eustachian tubes that are more horizontal (flat) than vertical and wide.

As soon as the child can stand, begin to measure the height in the upright position. A. True. Using the scale as soon as the child can stand next to it is fine. B. False. Measure the child standing starting between ages 2 and 3 years. C. It depends on when the child can stand independently. D. False. A child should always be measured in the recumbent position.

B. False. Measure the child standing starting between ages 2 and 3 years

Nutritional screening is an assessment of risk factors that A.indicate that the patient is at high nutritional risk. B.identify older adults who may require a more comprehensive assessment. C.calculate BMI and classify patients as obese versus malnourished. D.describe food frequency and microelements that may be lacking in the diet.

B. Identify older adults who may require a more comprehensive assessment.

The nurse is caring for a patient with a BMI of 33. Which nursing diagnosis is most appropriate? A. Imbalanced nutrition: less than body requirements B. Imbalanced nutrition: more than body requirements C. Fluid volume excess D. Fluid volume deficits

B. Imbalanced nutrition: more than body requirements

The patient is complaining of abdominal pain. What technique is used to form an overall impression? A.Auscultation B.Light palpation C.Direct percussion D.Deep palpation

B. Light palpation

To correctly document that ROM in the fingers is full and active, you would write that the patient can. A. perform rotation, lateral flexion, and hyperextension. B. make a fist, spread and close fingers, and do finger-thumb opposition. C. touch finger to own nose and to examiner's finger back and forth. D. perform supination, pronation, and lateral deviation.

B. Make a fist, spread and close fingers, and do finger-thumb opposition.

A mother brings her 6-month-old infant to the clinic for a routine evaluation. At birth, the term infant weighed 3.5 kg (7 lb 12 oz) and was 51 cm (20 in.) long. He now weighs 4.6 kg (10 lb 2 oz). Which assessments are most important for you to do next? A.Obtain a thorough obstetrical and neonatal history and say, "I'm very worried that the baby hasn't gained more weight. What are you feeding him?" B.Measure head and chest circumference and length, then plot current weight, length, and head and chest circumferences on standardized growth charts. C.Review the immunization history, administer the Denver II assessment, and ask the mother if she has noticed any unusual patterns or behaviors. D.Screen for domestic violence and focus on the neurological, cardiac, and abdominal portions of the physical examination.

B. Measure head and chest circumference and length, then plot current weight, length, and head and chest circumferences on standardized growth charts.

In the SBAR reporting format, which of the following would be an example of data found in the assessment? A.Mrs. Kelly's diagnosis is Stage II breast cancer. B.Mr. Imami's lung sounds are decreased. C.Ms. Choi needs to have a social work consult. D.Mr. Jones was admitted at 10:30 this morning.

B. Mr. Imami's lung sounds are decreased.

Nell, 50 years old, is worried about whether her intelligence will change as she continues to advance through middle age. What can the nurse tell Nell about what might happen to her cognitive skills in middle age? A. Nell can expect her vocabulary to gradually decrease over time B. Nell can expect to be slightly slower as she does cognitive tasks C. Nell will have great difficulty learning new skills D. Nell will find that her life experience is unhelpful in problem solving

B. Nell can expect to be slightly slower as she does cognitive tasks

A dorsalis pedis of +1/4 may indicate A.DVT. B.PAD. C.Raynaud disease. D.Lymphadenopathy.

B. PAD

Which of the following peripheral vascular diseases is not known to have a hereditary component? A.Lymphadenopathy B.Raynaud disease C.Abdominal aortic aneurysm D.PAD

B. Raynauds disease

As part of the MMSE, you ask the patient to immediately state three words. This is a measure of which of the following?A.Orientation B.Registration C.Recall D.Attention

B. Registration.

Which of the following indicators would be most likely to signify to the nurse that a patient is having pain? A. Falling asleep B. Rubbing a body part C. Relaxed body position D. Facial droop

B. Rubbing a body part

A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpates a mass that feels like "a bag of worms." These findings are consistent with which condition? A.Hydrocele B.Varicocele C.Spermatocele D.Epididymitis p. 700

B. Varicocele

Use of the GCS provides relatively objective assessment of LOC, The three functions assessed are: A. Pupil reaction, orientation, and sensation B. Verbal response, eye opening, and motor response. C. eye opening, motor response, and sensation. D. verbal response, Pupin reaction, and motor response

B. Verbal response, eye opening, and motor response

The nurse is performing patient teaching about normal changes during late pregnancy. These include which of the following? A.Dark cloudy urine B.Waddling gait C.Vaginal bleeding D.Sudden edema

B. Waddling gait

The nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. The nurse interprets this as A.a normal finding over the trachea. B.a normal finding over the bronchi. C.an abnormal finding over the lung. D.an abnormal finding over the trachea.

B. a normal finding one the bronchi

A patient is having adverse effects resulting from a medication. The nurse calls the primary care provider to request a change in the medication order. The nurse is functioning as a/an A. educator. B. advocate. C. organizer. D. counselor.

B. advocate

When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment? A.Breath sounds B.Airway patency C.Respiratory rate D.Percussion sounds

B. airway patency

Which of the following is the healthiest eating plan? Select all that apply: A. excludes lean meats, poultry, and fish B. allows for moderate intake of salt and sugars C. with non or low-fat milk and dairy products D. emphasizes fruits, vegetables, and whole grains

B. allows for moderate intake of salt and sugars C. with non or low-fat milk and dairy products D. emphasizes fruits, vegetables, and whole grains

The nurse practitioner is assessing a patient with frequent candidiasis. The test that the nurse will order for this patient is A.cultures for chlamydia. B.a blood test for glucose. C.a blood test for syphilis. D.a vaginal ultrasound.

B. blood test for glucose

While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for: A. dizziness B. Bowel/bladder incontinence C. difficulty swallowing D. arm weakness

B. bowel/bladder incontinence

All the following may be symptoms of a child experiencing lead poisoning except A. irritability B. cardiomegaly C. headaches D. abdominal pain

B. cardiomegaly

Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the first assessment you should make? A. Palpate for crepitus in the knee. B. Compare the swollen knee with the other knee. C. Assess active ROM in the knee. D. Feel the knee for warmth.

B. compare the swollen knee with the other knee.

When assessing the lower extremities, it is critical that the examiner A.starts at the feet. B.compares side to side. C.evaluates the venous system and then the arterial system. D.starts at the femoral area. 4

B. compares side to side

With transcultural assessment, the nurse must A.ask all the questions for completeness. B.determine which questions to ask. C.include all the questions as part of an admitting assessment. D.wait until the relationship is established to ask questions.

B. determine which questions to ask.

Signs and symptoms that are "red flags" for violence include which of the following? A.Stating that everything is just fine B.Displaying mood and behavior changes C.Expressing sadness over loss D.Wanting to have family involved

B. displaying mood and behavior changes

The social context influences the patterns of health and illness for individuals, communities, and societies. An example is the assessment of A.the patient's health beliefs and practices. B.focus groups in multiple locations. C.culture-based postpartum practices. D.the religious practices of the patient.

B. focus groups in multiple locations.

A patient with diabetes mellitus who closely monitors and controls her blood glucose level is very interested in preventing complications of her illness. Which teaching is a priority for the patient related to peripheral vascular circulation? A.How to count calories. B.How to assess her feet daily. C.Choosing complex carbohydrates D.Identifying venous insufficiency.

B. how to assess her feet daily.

While reviewing laboratory values for thyroid function in an adult patient, the nurse sees that the TSH is elevated, and T3 and T4 are decreased. The nurse recognizes that these findings are indicative of A.normal thyroid function. B.hypothyroidism. C.hyperthyroidism. D.thyroid cancer.

B. hypothyroidism

An adolescent male presents with complaints of nosebleeds. The nurse would further assess for A.hemangioma. B.nasal trauma. C.angiofibroma. D.cystic fibrosis.

B. nasal trauma

The nurse has assessed the nose and documents expected findings as A.nose asymmetrical with clear drainage. B.nose symmetrical and midline. C.nose asymmetrical and proportional to facial features. D.nose symmetrical with yellow drainage.

B. nose symmetrical and midline

A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? A.Listen for a fluid wave B.Percuss the abdomen for shifting dullness C.Auscultate for lymph nodes D.Stroke the abdomen to elicit the abdominal reflex

B. percuss the abdomen for shifting dullness

A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion? A.Papule B.Pustule C.Cyst D.Vesicle

B. pustule

A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot the he left a pan on the stove. The nursing diagnosis that is highest priority is: A. ineffective brain tissue perfusion B. risk for injury C. acute confusion D. impaired memory

B. risk for injury

Which of the following descriptions is most consistent with a patient who has hypothyroidism? A.Slightly obese, perspiring female, who complains of feeling cold all the time and having diarrhea. B.Slightly obese female with periorbital edema, who complains of cold intolerance, brittle hair, dry skin. C.Thin, anxious-appearing female with exophthalmos and a rapid pulse and who complains of diarrhea. D.Thin, perspiring male with a deep hoarse voice, facial edema, a thick tongue, and reports of diarrhea.

B. slightly obese female with periorybital edema, who complains of cold intolerance, brittle hair, dry skin.

Which assessment findings would indicate that inhaled bronchodilators have been effective? A.Expiratory wheezing, O2 saturation 94%, pallor B.Vesicular breath sounds, O2 saturation 96%, pink C.Bronchial breath sounds, O2 saturation 100%, erythema D.Crackles, O2 saturation 90%, circumoral cyanosis

B. vesicular breath sounds, O2 saturation 96%, pink.

A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? A.How often do you have a bowel movement? B.What was your bowel pattern before you noticed the change? C.Is there a family history of irritable bowel syndrome? D.Have any of your parents or siblings had cancer of the colon?

B. what was you bowel pattern before you noticed the change?

It is important to examine the upper outer quadrant of the breast because it is A.more prone to injury and calcifications. B.where most breast tumors develop. C.where most of the suspensory ligaments attach. D.the largest quadrant of the breast.

B. where most breast tumors develop

"Do you have any thoughts of wanting to kill or harm yourself?" is a common question to assess for suicidal ideation because it A. is blunt and patients cannot refuse to answer. B. will cover both suicidal and parasuicidal thoughts. C. is subtle, and patients will not know how to answer. D. will encourage patients who perform self-harm to stop cutting.

B. will cover both suicidal and parasucidal thoughts.

You are triaging infants who have presented to the emergency department on a Friday night. Which infant should you take in for treatment first? A.A 2-week-old infant whose mother reports, "She just won't stop crying. I'm so worried." The cry is medium pitch; temperature 37°C (99°F), HR 160 beats/min, RR 50 breaths/min; abdomen moves with each breath. B.A 6-week-old infant whose father reports, "He's vomited several times and he won't take his bottle." Temperature 36°C (96.8°F), HR 70 beats/min, RR 20 breaths/min. His lips are white. He is limp. C.A 5-month-old infant with a stuffy nose who has been unusually fussy and has had three loose stools in the past 8 hours. Temperature 37.6°C (99.8°F), HR 140 beats/min, RR 45 breaths/min while crying. D.An 8-month-old infant whose parents report he choked on a bean at dinner. The bean came out after five back pats. He turns blue around his mouth when he cries. Temperature 37°C (98.6°F), HR 130 beats/min, RR 30 breaths/min.

B.A 6-week-old infant whose father reports, "He's vomited several times and he won't take his bottle." Temperature 36°C (96.8°F), HR 70 beats/min, RR 20 breaths/min. His lips are white. He is limp.

Which of the following interventions is most important to prevent nosocomial infections? A.Proper glove use B.Hand hygiene C.Appropriate draping D.Quiet environment

B.Hand hygiene

A 20-year-old Caucasian man complains of a mass in his left testicle. In addition to his age and race, what else is a risk factor for testicular cancer? A.Colon cancer in his mother B.Personal history of cryptorchidism C.UTI in the previous month D.Congenital hydrocele

B.Personal history of cryptorchidism

Which of the following is a normal ABI? A.56 B.87 C.1.0 D.24

C. 1.0

Oscar, 6 years old, has come to the well-child clinic for a visit. He is 1.16 m (46 in) tall today. Assuming that he grows at an expected pace, how tall would the nurse expect Oscar to be at 10 years? A. 1.27 m (50 in) B. 1.32 m (52 in) C. 1.37 m (54 in) D. 1.57 m (62 in)

C. 1.37 m (54 in)

Michelle's fundal height measures 28 cm (11 in.). You expect the gestational age to be A.20 weeks. B.14 weeks. C.28 weeks. D.30 weeks.

C. 28 weeks

Which of the following patients is at highest risk for complications related to folate deficiency? A. A 3-year-old boy who is developmentally delayed B. A 15-year-old girl who just started her menses C. A 24-year-old woman who is attempting pregnancy D. An 82-year-old man living in a nursing home

C. A 24-year-old woman who is attempting pregnancy

After receiving patient information from the previous shift nurse and gathering data from the chart, the nurse will assess a group of four patients. Which one will the nurse assess first? A.A 32-year-old man with an open wound who is receiving antibiotics B.A 66-year-old woman 2 days postoperatively following ankle surgery C.A 45-year-old man with HIV and Pneumocystis jiroveci pneumonia with dyspnea D.An 88-year-old woman with confusion who had a stroke 4 days ago

C. A 45 year old man with HIV and pneumocystis jiroveci pneumonia

The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing A. whether the patient is a reliable historian. B. functional health patterns. C. ADLs. D. review of systems.

C. ADLs

Tympany is a percussion sound commonly located in the A.thorax. B.upper arm. C.abdomen. D.lower leg.

C. Abdomen

Strategies for effective handoffs during change-of-shift report are to A.tape-record the report for efficiency. B.vary the format to individualize to the patient. C.allow an opportunity to ask and answer questions. D.put report in writing so that the next shift care provider can get right to work.

C. Allow an opportunity to ask and answer questions.

You auscultate a loud murmur in an older adult patient. You should also assess for which of the following? A.Coarse rhonchi and purulent sputum B.Irregular heartbeat and pulse deficit C.Crackles in the lungs and leg edema D.Abdominal distention and liver tenderness

C. Crackles in the lungs and leg edema

From the given list, select the older adult at greatest risk for malnutrition: A. A 67-year-old married man with poor dentition B. A 73-year-old woman in a nursing home C. An 80-year-old widow who lives alone D. A 78-year-old widower who receives food from Meals on Wheels

C. An 80-year-old widow who lives alone

The best way to assess a client's respiration rate is by: A. Place a hand over the clients chest and count for 30 seconds B. Observe and count respirations for 30 seconds and multiply by two without mentioning that you are observing the respirations C. Ask the client to breath normally for one minute D. If respirations are irregular have the client rest for 10 minutes and then recount

C. Ask the client to breath normally for one minute

The nurse assesses a patient presenting with nausea, vomiting, and diarrhea. In performing the focused assessment, the nurse uses the following techniques: A.Auscultate lungs, auscultate heart, auscultate abdomen. B.Evaluate for dehydration, assess skin turgor, auscultate lungs. C.Auscultate abdomen, palpate abdomen, evaluate for dehydration. D.Palpate abdomen, percuss abdomen, auscultate heart.

C. Auscultation abdomen, palpate abdomen, evaluate for dehydration

A patient comes into the clinic for a scheduled NST when the nurse notes that the FHR tracing is nonreactive. Which of the following actions would be appropriate for the nurse to do first? A.Document the findings. B.Notify the provider. C.Change the mother's position. D.Instruct the patient to return to the clinic in 1 week for reevaluation of the fetal heart rate.

C. Change the mother's position

Which of the following statements is true concerning changes in the older adult?A.The lens becomes smaller and less dense. B.The tympanic membrane becomes more flexible and retracted. C.Changes in the inner ear can interfere with sound discrimination. D.Increased pupillary responses lead to difficulty in light accommodation.

C. Changes in the inner ear can interfere with sound discrimination

The patients radial pulse is weak and thready. The next action of the nurse is to A. Transfer the patient to a critical care unit B. Notify the primary care provider C. Compare findings with previous findings and opposite extremity D. Assess vital signs every 15 min.

C. Compare findings with previous findings and opposite extremity

A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform on admission? A. Emergency B. Focused C. Comprehensive D. Illness

C. Comprehensive

Caitlyn was about 50cm (20in.) long at birth and weighed 3kg (7lb, 8oz). At her 1-year well-child checkup, the nurse determines that Caitlyn is 66cm (26in) and weights 7kg (16lbs). The nurse's reaction to these assessment findings is to be: A. Concerned; Caitlyn should have quadrupled her birth weight by now B. Unconcerned; Caitlyn is growing in height and weight at an expected pace C. Concerned because Caitlyn should have tripled her birth weight by now D. Unconcerned because Caitlyn has slightly more than doubled her birth weight

C. Concerned because Caitlyn should have tripled her birth weight by now

Which of the following conditions would be the highest priority to contact the health care provider about? A.Striae gravidarum B.Varicosities of the labia C.Contractions before 37 weeks D.Prominent Montgomery glands

C. Contractions before 37 weeks

You obtain a blood pressure reading of 110/70 mm Hg (left arm) in a 5-year-old boy. What would you do about this blood pressure? A. Call the physician immediately B. Bring the child back to the clinic two more times to ensure accuracy of the assessment C. Determine the blood pressure percentile based on age, sex, and height percentiles D. It is normal; nothing needs to be done

C. Determine the blood pressure percentile based on age, sex, and height percentiles.

The purpose of auditing charting is to A.enhance nurses' learning and understanding of complex clinical situations. B.identify staff members who document completely and counsel those who do not. C.determine whether staff members are providing and documenting standards of care. D.locate data in the chart the evening before a morning clinical visit.

C. Determine whether staff members are providing and documenting standards of care

The nurse usually performs a complete physical examination with elements in the following order: A.Face, heart, legs, arms B.Head, abdomen, lungs, legs C.Eyes, heart, abdomen, legs D.Ears, back, lungs, arms

C. Eyes, heart, abdomen, legs

A woman who is pregnant is being screened for adequate intake of calcium and vitamin D. Which of the following tools is most appropriate for the nurse to administer? A. 24-hour recall B. 3-day diet history C. Food frequency questionnaire D. Comprehensive nutrition assessment

C. Food frequency questionnaire

Which of the following is an appropriate use of gloves? A.Gloves are worn during anticipated contact with intact skin. B.Gloves are removed when going from clean to contaminated areas. C.Gloves are worn during anticipated contact with body secretions. D.Gloves are removed when assessing the back of an

C. Gloves are worn during anticipated contact with body secretions.

An infant has a new onset of rash but otherwise seems well. Which interview question is best when trying to pinpoint a possible cause? A."Was there a prolonged NICU stay?" B."What treatments have you given her for the rash?" C."Has anything changed lately, such as shampoos, soaps, or laundry detergent?" D."How many diapers is she wetting per day, and what is the stool pattern?"

C. Has anything changed lately, such as shampoo, soaps, or laundry detergent?

Which of the following 6-month-old infants has the most markers for a possible genetic disorder? A.Has large ears, is in the 95th percentile for weight and height, babbles B.Has large scaly plaques on face and torso, red reflex is absent in one eye, posterior fontanelle has closed C.Has significant head lag, one ear is small and malformed, nipples are unusually close together D.Sits up alone, cranial sutures are palpable, back of the head is flat

C. Has significant head lag, one ear is small and malformed, nipples are unusually close together

A clinical nurse is assessing a patient's knowledge and understanding of bone health and maintenance. Which of the following responses of the patient indicates adequate understanding to maintain musculoskeletal health? A. I will take calcium supplementation as prescribed and eat plenty of citrus fruits. B. I will expose myself to sunlight at least 1 hour daily and eat plenty of green, leafy vegetables. C. I will take calcium supplementation and vitamin D as prescribed. D. I will exercise daily and take vitamin E as prescribed.

C. I will take calcium supplementation and vitamin D as prescribed.

When examining the breast of a 75-year-old woman, the nurse would expect to find which of the following? A.Enlarged axillary lymph nodes B.Multiple large firm lumps C.A granular feel to the breast tissue D.Pale areola

C. a granular feel to the breast tissue

The nurse is assessing the nares to evaluate the site of epistaxis. The most common site of bleeding is which of the following? A.Ostiomeatal complex B.Nasal septum C.Kiesselbach plexus D.Woodruff plexus

C. Kiesselbach plexus

When doing an assessment of the spine of an older adult, you can expect to see which variation? A. Lordosis. B. Torticollis. C. Kyphosis. D. Scoliosis

C. Kyphosis

Which of the following findings are considered an expected change in the skin in older adults? A.Solar lentigines (liver spots) B.Actinic keratoses C.Loss of subcutaneous fat D.Photoaging

C. Loss of subcutaneous fat

A young adult marathoner reports of right foot third metatarsal pain (6/10) and swelling for more that 4 weeks. An X-ray was ordered, and it did not show abnormal findings. Which of the following imaging might the nurse expect the physician to order? A. Repeat x-ray B. CT scan C. MRI D. Nuclear scintigraphy

C. MRI

Michelle says that her last normal menstrual period was June 15. Using the Nägele rule, her EDD is A.September 8. B.March 8. C.March 22. D.January 22.

C. March 22

The nurse assesses for possible complications of pregnancy. Which of these prompts referral to a perinatal specialist? A.Gastric reflux B.Previous cesarean procedure C.Oligohydramnios D.Anemia

C. Oligohydramnios

A history of smoking has an extremely significant role in the development of which of the following? A.Venous insufficiency B.DVT C.PAD D.Raynaud disease

C. PAD

You are evaluating the growth pattern of a 5-month-old infant born at 27 weeks' gestation. Which of the following actions will yield the most accurate assessment of growth for this infant? A.Calculate how many kilocalories per day the infant is consuming, evaluate his bowel movement pattern, plot his measurements, and compare with the last two visits. B.Determine whether he has gained at least 2.2 kg (5 lb) since birth, because infants should gain 500 g to 1 kg (1 to 2 lb) per month in the first 6 months. C.Plot the weight and length on a standardized growth chart for a 7-week-old infant and compare with birth measurements and measurements on previous visits. D.Plot the weight and length on a standardized growth chart for a 12-week-old infant and compare with birth measurements and measurements on previous visits.

C. Plot the weight and length on a standardized growth chart for a 7-week-old infant and compare with birth measurements and measurements on previous visits.

Nurses advocate for underserved populations to reduce health disparities. This promotes A. autonomy. B. altruism. C. respect. D. human dignity.

C. Respect

The practitioner has decided to place a patient on isotretinoin for her acne problems. The nurse is preparing to counsel the patient. What is the most important information she needs to tell the patient? A.She needs to take the medication daily and avoid missing a dose. B.She should not take this medication with antibiotics. C.She needs to use two forms of birth control or abstain from sex 1 month before, during, and 1 month after taking this medication. D.She needs to take a weekly pregnancy test to make sure she has not gotten pregnant while on this medication.

C. She needs to use two forms of birth control or abstain from sex 1 month before, during, and 1 month after taking this medication.

The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as. A. Atony B. Tremors C. Spasticity D. Fasciculation

C. Spasticity.

What technique facilitates accurate auscultation? A.Earpieces of the stethoscope are positioned to point toward the back. B.The tubing of the stethoscope is long and dark in color. C.The chestpiece of the stethoscope is sealed against the skin. D.The diaphragm of the stethoscope is used for low-frequency sounds.

C. The chestpiece of the stethoscope is sealed against the skin.

Which of the following is the rationale for the nurse to reassess the patients pain after treatment? A. To pinpoint the pains location B. To measure the pains duration C. To establish the efficacy of medication D. To make changes to the patients pain goal

C. To establish the efficacy of medication

To identify the location of pain, the nurse asks the patient A. How long he or she has had the pain B. To rate the intensity of the pain on a scale from 0-10 C. To point to the painful area D. To describe the quality of the pain

C. To point to the painful area

Which of the following would you recognize as an unexpected finding while examining the male genitalia? A.Smegma is present on the uncircumcised patient. B.Testes are palpable and firm within the scrotal sac. C.You note an impulse at the tip of your finger during hernia examination. D.The urethral meatus has a slitlike opening central to the distal tip of the glans.

C. You note an impulse at the tip of your finger during hernia examination

The nurse is admitting a 75-year-old man with a 50-year history of smoking 1 pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is A.pitting. B.thickening and discoloration of the nail bed. C.clubbing. D.brittleness and cracking of the nails.

C. clubbing

A shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world is defined as A.society. B.community. C.culture. D.spirituality.

C. culture

A 23-year-old nulliparous woman is concerned that her breasts seem to change in size all month long and they are very tender around the time she has her period. The nurse should explain to her that A.nonpregnant women usually do not have these breast changes and this is cause for concern. B.breasts often change in response to stress, so it is important to assess her life stressors. C.cyclical breast changes are normal. D.breast changes normally occur during pregnancy and she should have a pregnancy test.

C. cyclical breast changes are normal

A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high blood pressure. What concept should the nurse use when performing patient teaching? A.Teach the patient the most serious information. B.Give the patient brochures to review before the next visit. C.Discuss risk factors that the patient is interested in modifying. D.Describe consequences of risk factors to motivate the patient.

C. discuss risk factor that the patient is interested in modifying.

Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of A.perseveration. B.auditory hallucinations. C.divergent tactics. D.altered mood.

C. divergent tactics

Physical examination of a patient reveals an enlarged tonsillar node. Acutely infected nodes would be A.hard and nontender. B.fixed and soft. C.firm but movable and tender. D.irregular and hard.

C. firm but movable and tender.

A patient calls the provider's office to schedule an appointment because a home pregnancy test was positive. The nurse knows that the test identified the presence of which of the following in the urine? A.Estrogen B.Progesterone C.hCG D.Follicle-stimulating hormone

C. hCG

A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? A.Inspection with indirect lighting B.Iliopsoas muscle sign C.Indirect percussion for CVA tenderness D.Blumberg sign

C. indirect percussion for CVA tenderness

When gathering the family history, the nurse draws a genogram A. using circles for males and squares for females. B. putting the patient on the left to show birth order. C. inserting lines between parents to show marriage. D. listing health problems above the symbol for the patient.

C. inserting lines between parents to show marriage

When performing an abdominal assessment, what is the correct sequence? A.Inspection, palpation, percussion, auscultation B.Palpation, percussion, inspection, auscultation C.Inspection, auscultation, percussion, palpation D.Auscultation, inspection, palpation, percussion

C. inspection, auscultation, percussion, palpation

A 22-year-old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in.) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion? A.Crust B.Lichenification C.Keloid D.Scale

C. keloid

Normal speech is audible. This is a normal finding describing which quality of speech? A.Fluency B.Quality C.Loudness D.Articulation

C. loudness

Seeking understanding of patients' culture-based health care practices is essential to nursing because each culture has its own traditional values and beliefs about health and illness that A.have things that need to be avoided. B.affect the body image and habits that may lead to becoming overweight. C.may affect patients' adherence to treatments. D.use various health methods that might be harmful.

C. may affect patients' adherence to treatments.

When questioning a patient about violence, it is best to A.ask to get the police involved to collect evidence. B.have the perpetrator present to assess his or her behaviors. C.move from general to specific questions. D.ask the patient what he or she did to provoke the violence.

C. move from general to specific questions.

When assessing hydration, the nurse will A.pinch a fold of skin on the medial aspect of the forearm and observe for recoil to normal. B.pinch a fold of skin on the abdomen and observe for recoil to normal. C.pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal. D.pinch a fold of skin on the head and allow for skin to recoil in children.

C. pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal.

The seven Ps of an acute arterial occlusion include A.polythermia. B.popliteal pallor. C.poikilothermia. D.pitting edema.

C. poikilothermia

The purpose of comparing culture care needs of the specific individual with the general themes of people from similar cultural background is to A.identify the dietary needs of a specific religious preference. B.determine if the patient needs a spiritual consultation. C.provide a picture of the individual's culture-based health care needs. D.consider how closely the patient follows his or her religion.

C. provide a picture of the individuals culture-based health care needs.

When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A.Right renal artery B.Right femoral artery C.Right iliac artery D.Abdominal aorta

C. right iliac artery

The nurse assessing an older adult focuses the health history on A. previous pregnancies, obstetrical history, and psychosocial factors. B. birth history, immunizations, and growth and development. C. sensory deficits, illness history, and lifestyle factors. D. religion, spirituality, culture, and values.

C. sensory deficits, illness history, and lifestyle factors

The correct position in which to place the patient to palpate the breasts is A.left lateral position with arm over head. B.sitting forward with hands on hips. C.supine with arm over head. D.supine with arms at side.

C. supine with arm over head

In a healthy patient, the myocardial cells in the ventricle depolarize and contract during A.prediastole. B.diastole. C.systole. D.postsystole.

C. systole

The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following? A.The bilateral carotid pulse B.The presence of bruits C.The highest level of jugular venous pulsation D.The strength of the jugular veins

C. the highest level of jugular venous pulsation

Which of the following is part of the upper gastrointestinal tract? A.Nasal septum B.Sinuses C.Throat D.Adenoids

C. throat

Which of the following factors is the most significant risk factor for COPD? A.Increased age B.Immune suppression C.Tobacco smoking D.Occupational exposure

C. tobacco smoking

The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient A.clench his or her teeth during muscle palpation. B.bring his or her head to the chest. C.turn his or her head against resistance. D.extend his or her arms against resistance.

C. turn his or her head against resistance

Abnormal movements from side effects of medications might be described as A.voluntary. B.deliberate. C.uncoordinated. D.smooth and even.

C. uncoordinated

The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the A. preinteraction phase. B. beginning phase. C. working phase. D. closing phase.

C. working phase

When teaching the breast self-examination, the nurse should inform the woman that it is best to perform the exam is which of the following times? Select all that apply. A.Just before the menstrual period B.Just after the menstrual period C.On the 4th to 7th days of the menstrual cycle D.On the 10th day of the menstrual cycle

C.On the 4th to 7th days of the menstrual cycle

When examining the scrotum of an adult Hispanic male, a normal finding is A.symmetrical scrotal sac with two movable testes. B.smooth, rubbery, saclike surface that is sensitive to gentle compression. C.asymmetrical sac with left side lower than right side. D.reddish colored skin that is darker than general body skin and has sebaceous cysts.

C.asymmetrical sac with left side lower than right side.

Which of the following patients should not have a temperature measured orally? A. And 84 year old woman with diarrhea B. A 30 year old patient with an earache C. A 45 year old man with chest pain D. A 62 year old woman who has had oral surgery

D. A 62 year old woman who has had oral surgery

Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on A.an admission assessment B.a PO C.a progress note D.a focused assessment flow sheet

D. A focused assessment flow sheet.

The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is A. "Don't cry. It will be OK." B. "My mother has the same thing." C. "I think that you should have surgery." D. "I'll stay with you" (gets a tissue).

D. "I'll stay with you" (gets a tissue).

The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is A. "You must be extremely worried." B. "I'd be in worse shape than you are if it were my baby." C. "Is there anyone here that you can talk to?" D. "You seem worried, but I need to ask a few questions."

D. "You seem worried, but I need to ask a few questions".

When charting general appearance and behavior, documentation may include which of the following? A."Alert and oriented × 3." B."Thought logical." C."Judgment intact." D."Clothes disheveled"

D. "clothes disheveled"

The patient has findings of cognitive decline, minimal to no intake of nutrition, and neglect of the home environment and finances. Which of the following is the appropriate nursing diagnosis? A.Disturbed sensory perception B.Impaired individual coping C.Imbalanced nutrition, less than body requirements D.Adult failure to thrive

D. Adult failure to thrive.

Health promotion for children should incorporate teaching about lifelong cardiovascular health, including which of the following? A.Information on good nutrition B.Information on the prevention of illnesses C.Information on exercise D.All of the above

D. All of the above

A patient says that his pain worsens with weight-bearing activity. The nurse would consider this A. An alleviating factor B. A functional pain goal C. A quality/description D. An aggravating factor

D. An aggravating factor

Latex allergies A.always result in anaphylactic reactions and shock. B.can be reduced by moisturizing the hands after washing. C.cannot be caused by equipment such as a stethoscope. D.are more common in nurses and in frequently hospitalized patients.

D. Are more common in nurses and in frequently hospitalized patients

When speaking with a frail older adult, it is best to A.fill in silences to avoid discomfort. B.address all questions to the patient's family. C.rely on the patient's memory when gathering all information. D.ask questions using lay terms rather than medical terms.

D. Ask questions using lay terms rather than medical terms

If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following? A. Hyporeflexia B. Normal plantar reflex C. Cushing syndrome D. Babinski sign

D. Babinski sign

You are teaching a parenting class, and the parents are sharing baby pictures. Which picture indicates that the parent may need additional education? A.Baby is playing peek-a-boo in his car seat, which is installed in the middle part of the rear seat. B.Daddy is brushing his son's two front teeth while baby is splashing in the bathtub C.Baby (10 months old) is in his high chair feeding himself banana cut in small pieces. D.Baby is sleeping supine in her crib, no pillow, one blanket, bottle lying beside baby and a tiny dribble of milk at the corner of her mouth.

D. Baby is sleeping supine in her crib, no pillow, one blanket, bottle lying beside baby and a tiny dribble of milk at the corner of her mouth

The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral assessment is important because of the increased risk for which of the following? A.Fordyce granules B.Pharyngitis C.Anosmia D.Candida albicans

D. Candida albicans

A man had a motor vehicle accident and fractures his right ankle. He was transferred from the emergency department to the orthopedic nursing unit for further observation and possible surgery in the next 12 hours. What is the priority nursing assessment of the admitting orthopedic nurse? A. Temperature B. Capillary refill proximal to the injury of the right ankle. C. Capillary refill distal to the injury of the left ankle. D. Capillary refill distal to the injury of the right ankle.

D. Capillary refill distal to the injury of the right ankle.

The nurse performing the first assessment on the hospitalized patient and documents it in the chart as the: A.sporadic assessment. B.functional assessment. C.focused assessment. D.comprehensive assessment.

D. Comprehensive

Upon inspection, the nurse sees flesh-colored lesions surrounding the anal area. These lesions most likely indicate A.hemorrhoids. B.herpes simplex virus 2. C.AIDS. D.condyloma acuminatum infection.

D. Condyloma acuminatum infection

Your patient with a humerus fracture is stating pain of 5 on a 10-point scale. His hand is pale, cool, and swollen. His pain medication is ineffective, and he is at risk for impaired circulation. What action will the nurse take first? A.Reassess the pain in 30 minutes and contact the provider if unresolved. B.Give additional pain medication and reassess the pain in 30 minutes. C.Document the abnormal findings and give an extra dose of pain medication now. D.Contact the primary care provider and document the findings now.

D. Contact the primary care provider and document the findings now.

During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patient, which causes the ipsilateral testicle to rise. What superficial reflex is demonstrated? A.Abdominal reflex B.Babinski reflex C.Brachioradialis reflex D.Cremasteric reflex

D. Cremasteric Reflex

The proper technique for correcting written documentation is to A.use correction fluid and write over the error. B.completely black out the error with a black marker. C.write over the error in darker ink. D.draw a line through the error and write the date, time, reason for error, and your initials.

D. Draw a line through the error and write the date, time, reason for error, and your initials.

Which of the following activities best facilitates anticipatory guidance? A.Becoming very proficient in interviewing and performing the physical examination B.Doing as much of the examination as possible with the infant in the parents' lap C.Recognizing and reporting signs of physical abuse and neglect D.Encouraging parents to make an appointment with the pediatrician before the baby is born

D. Encouraging parents to make an appointment with the pediatrician before the baby is born

The nurse assesses whether the patient outcome "Patient drinks 1 liters every shift" has been met. This is called A.assessment. B.planning. C.implementation. D.evaluation.

D. Evaluation

Which of the following are components of a comprehensive health assessment? A. Nursing diagnoses B. Goals and outcomes C. Collaborative problems D. Examination of body systems

D. Examination of body systems

Adult patients may have variations in pulse rates with A. respirations. B. food intake. C. heat. D. exercise.

D. Exercise

A child's head circumference is a measurement that should be obtained at every well-child visit until the child is 5 years old. A. True. This measurement is indicative of brain growth. B. False. One or two measurements are the standard of care. C. True. It will provide information on the child's readiness for kindergarten. D. False. The charts for head circumference norms end at 36 months of age.

D. False. The charts for head circumference norms end at 36 months of age

The patient has serum values that are abnormal for sodium and potassium. The nurse recognizes that these values are important to maintain in normal range for proper: A. tissue oxygenation B. tensile strength in the hair C. oil production in the skin D. fluid and electrolyte function

D. Fluid and electrolyte function

A 90-year-old patient has a drooped body position, appears sad, and says that she has seasonal affective disorder. What tool would the nurse use to assess her? A.MMSE B.CAGE C.SAD PERSONAS assessment D.Geriatric Depression Scale

D. Geriatric depression scale

After completing a history on a 45-year-old patient, the nurse suspects the patient may have uterine fibroids. What information might have led her to this conclusion? A.History of STIs B.History of multiple births C.Vaginal discharge D.Heavier than usual menstrual periods

D. Heavier than usual menstrual periods

Which sexually transmitted infection presents with painful red superficial vesicles along the penis or on the glans? A.Gonorrhea B.Chlamydia C.Syphilis D.Herpes simplex virus 2 (HSV-2)

D. Herpes simplex virus 2 (HSV-2)

The nurse is caring for a patient who is admitted to the hospital with a possible ectopic pregnancy. Which of the following nursing actions is the priority? A.Monitoring daily weight B.Assessing for edema C.Monitoring the temperature D.Monitoring the blood pressure

D. Monitor the blood pressure

Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment procedures should the nurse perform next? A. Trendelenburg and drawer signs. B. McMurray and Thomas tests C. Bulge test and ballottement D. Phalen and Tinel tests.

D. Phalen and Tinel tests.

A patient is admitted the hospital with multiple trauma from an automobile accident 5 days ago. Which of the following is the best indicator of current nutritional status? A. Transferrin B. Total protein C. Albumin D. Prealbumin

D. Prealbumin

The nurse is preparing the patient for her genital examination. What position will the nurse assist the patient into for a comfortable genital examination? A.Semi-Fowler B.Prone with her knees bent C.Supine with her knees bent D.Semi-lithotomy

D. Semi-lithotomy

You are inspecting the groin of an older adult man who lives in a long-term care facility. Which of the following is an expected finding that you will document? A.Pediculosis in hair distribution B.Hypospadias on the glans C.Yellow discharge from the meatus D.Smegma under the foreskin

D. Smegma under the foreskin

Which of the following is a barrier to pain assessment? A. The nurse believes that patients suffer if under-medicated B. The nurse focuses on pain relief as a primary end to the assessment process C. The nurse chooses treatment that will positively affect the patients care D. The nurse has difficulty in accepting the patients self-report as valid

D. The nurse has difficulty accepting the patients self-report as valid

What might the nurse suggest to Manuel, age 35, to improve his memory now that he has entered into early adulthood? A. Reflective thinking B. Use only logical analysis to systematically consider all the pros and cons C. Be more practical, considering the complexities of the situation D. Use organization and imagery to remember things

D. Use organization and imagery to remember things

Which of the following processes is the most important when providing nursing care to an ill patient? A. Writing outcomes B. Performing a focused assessment C. Collecting objective data D. Using critical thinking

D. Using critical thinking

The nurse is inspecting the urethra and the Skene glands. She knows these are a part of what area? A.Mons pubis B.Vulva C.Posterior fourchette D.Vestibule

D. Vestibule

The chart states that a 62 year old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following? A. Tremors on the left side of the face. B. Tremors on the right side of the face. C. Weakness in the right arm D. Weakness in the left arm.

D. Weakness in the left arm.

Which of the following infants has the most signs that point to possible abuse? A.History of a long NICU stay for extreme prematurity; does not respond to loud clapping B.Positive Ortolani and Barlow maneuver results; one leg looks shorter than the other C.Small baby with large areas of denuded skin on his face and torso D.When baby cries, mother says, "Shut up already." Baby has a foul odor and looks dirty.

D. When baby cries, mother says, "Shut up already." Baby has a foul odor and looks dirty.

What is the best time to assess the respiratory rate of a young child? A. While the child is crying B. While the child is playing in the playroom C. Immediately after taking the child's BP D. While the child is quietly sitting on the parent's lap

D. While the child is quietly sitting on the parent's lap.

The MMSE is used to assess for severity of alterations in orientation, registration, attention and calculation, recall, and language. For which of the following patients would the MMSE be most appropriate? A.Women during the postpartum period B.Adolescents struggling with sexual orientation C.Various cultural groups not tested by other tools D.Adults, to assess for cognitive impairment

D. adults, to assess for cognitive impairment

It is important to identify similarities and differences among the cultural beliefs of the patient, health care agency, and the nurse to A.get the proper diet. B.perform a spiritual consult. C.communicate with family. D.avoid making assumptions.

D. avoid making assumptions

The National Standards for Culturally and Linguistically Appropriate Services in Health Care mandate that standards A.should be applied in private offices. B.may be used in public settings. C.should be used in hospitals. D.be upheld in every health care setting.

D. be upheld in every health care setting.

You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to. A. stand up straight while you check the height of the iliac crest. B. flex the elbow and pull against your resistance. C. shrug both shoulders while you provide resistance. D. bend forward at the waist while you palpate the spine.

D. bend forward at the waist while you palpate the spine.

A male patient presents to the clinic with a complaint of a hard, irregular, nontender mass on his chest under the areola. Upon examination, the nurse notes that the mass is immobile and suspects A.gynecomastia. B.benign lesion. C.Paget disease. D.carcinoma.

D. carcinoma

While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of A.hyperthyroidism. B.hypothyroidism. C.malnutrition. D.dehydration.

D. dehydration

A 3-year-old boy is brought to the emergency department with stridor, nasal flaring, intercostal and supraclavicular retractions, and respiratory rate of 40 breaths/min. What type of situation is this? A.Stable B.Acute C.Urgent D.Emergency

D. emergency

A 92-year-old woman with a history of COPD presents with increasing shortness of breath, decreased lung sounds in the bases, increased ankle edema, and 5-lb weight gain in 1 week. What is the most likely problem? A.Impaired gas exchange B.Ineffective airway clearance C.Activity intolerance D.Excess fluid volume

D. excess fluid volume

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis? A.Ineffective cardiac tissue perfusion B.Decreased cardiac output C.Impaired gas exchange D.Excess fluid volume

D. excess fluid volume

Which of the following clusters of symptoms are common in women preceding an MI? A.Chest pain, nausea, diaphoresis B.Weight gain, edema, nocturia C.Dizziness, palpitations, low pulse D.Fatigue, difficulty sleeping, dyspnea

D. fatigue, difficulty sleeping, dyspnea

A patient with benign breast condition is likely to A.develop breast cancer later in life. B.require hormone replacement therapy. C.be a teenager. D.have it resolve after menopause.

D. have it resolve after menopause

The nurse documents the following information in a patient's chart: "Cough and deep breathe every hour while awake." This is an example of A. evidence-based nursing. B. priority setting. C. comprehensive assessment. D. nursing interventions.

D. nursing interventions

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority? A.Auscultate heart sounds. B.Inspect the precordium. C.Percuss the left border. D.Obtain pulse and blood pressure.

D. obtain pulse and blood pressure.

Which assessment technique best confirms splenic enlargement? A.Deep palpation under the left costal margin B.Fist percussion of the spleen with the patient in a sitting position C.Deep palpation over the RUQ with the patient lying on the right side D.Percussion along the left MAL spleen and gentle palpation

D. percussion along the left MAL spleen and gentle palpation

Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach? A.Please tilt your head back as far as possible. B.Please turn your head as far to the right as you can. C.Please bring your chin down toward your neck. D.Please tilt your head slightly down and to one side.

D. please tilt your head slightly down and to one side.

A patient presents with a complaint of drooping of the eyelid on one side. This finding is documented as which of the following? A.Kernig sign B.Pharyngitis C.Thyroglossal cyst D.Ptosis

D. ptosis

Mallory, 16 years old, is having difficulty in school and with her friends. She has not decided what she wants to do with the rest of her life after high school. Erik Erikson would say that Mallory is at risk for.. A. industry B. inferiority C. identity D. role confusion

D. role confusion

What is the nurse's best response when a Muslim patient has a basin of water on his bedside stand that he does not want emptied? A.Tell him that the water is a health hazard. B.Empty it because it could spill and get the bed wet. C.Talk with him about why he should not have it there. D.Support and accommodate his preference.

D. support and accommodate his preference.

The patients family should not be present with the patient during the interview about violence because: A. the patient may feel uncomfortable speaking openly with a relative present, especially if that person is contributing to the patient's stress. B. the patient may not insert questions related to the family member that could be perceived as insensitive or inappropriate. C. the family member may be ashamed or embarrassed by the patient's actions or statements and try to withhold or change the facts. D. the family member may be a perpetrator of abusive behavior, and thus the patient may be hesitant to honestly answer questions.

D. the family member may be perpetrator of abusive behavior, and thus the patient may be hesitant to honestly answer questions.

What percussion sound is heard over most of the abdomen? A.Resonance B.Hyperresonance C.Dullness D.Tympany

D. tympany

The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to A. role. B. self-perception. C. coping. D. values.

D. values

A patient reports swelling in her ankles. How would the nurse proceed with physical examination? A.Have the patient elevate her feet to better visualize her ankles. B.Measure her ankles at their widest point. C.Evaluate further for the brown hyperpigmentation associated with venous insufficiency. D.Press the fingers in the edematous area evaluating for a remaining indentation after the nurse removes his or her fingers.

D.Press the fingers in the edematous area evaluating for a remaining indentation after the nurse removes his or her fingers.

A 47 year old woman states she is having vertigo and some difficulty with balance. The nurse should assess: A. accommodation B. the whisper test C. shoulder strength D. soft touch

Not the correct answer because the book didn't have one of the options as the answer but it said: B. Balance and equilibrium are associated with cranial nerve VIII.

The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke: A. Low BP, lack of exercise, and diet high in fat B. High BP, diet high in fat, and smoking. C. Diet high in fat, smoking, and walking five times weekly. D. Obesity, swimming five times weekly, and high BP.

b. High BP, diet high in fat, and smoking.

The nurse assesses the child with purulent, unilateral nasal discharge. The nurse knows that the most likely causative factor is A.allergic rhinitis. B.choanal atresia. C.foreign body in nose. D.cystic fibrosis.

c. foreign body in nose

Tamika is often in a hurry with her toddler daughter Samantha and usually does things for her that Samantha could do herself if given more time. Erikson would say that Tamika's daughter a. will develop a healthy sense of autonomy because of her mother's help. b. will not develop shame and doubt because of these interactions with her mother. c. will develop a sense of autonomy no matter what her mother does. d. is at risk for developing a sense of shame and doubt because of her mother's behavior.

d. is at risk for developing a sense of shame and doubt because of her mother's behavior.