PA Final Exam

neurological

1. A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain?a. Frontal lobeb. Parietal lobec. Thalamusd. Temporal lobeANS: A 2. In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical manifestation to this injury?a. Intentional tremorsb. Visual changesc. Decreased hearingd. Inability to formulate wordsANS: B 3. While obtaining a symptom analysis from a patient who has an inner ear infection, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?a. I felt lightheaded when I stood up.b. I just could not keep my balance when I sat up.c. It seemed that the room was spinning around.d. I was afraid that I was going to lose consciousness.ANS: C 4. While obtaining a symptom analysis from a patient who had a transient ischemic attack, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?a. I felt lightheaded when I stood up.b. It felt like I was on a merry-go-round.c. The room seemed to be spinning around.d. My body felt like it was revolving and could not stop.ANS: A 5. Which patient behavior indicates to the nurse that the patients facial cranial nerve (CN VII) is intact?a. The patients eyes move to the left, right, up, down, and obliquely.b. The patient moistens the lips with the tongue.c. The sides of the mouth are symmetric when the patient smiles.d. The patients eyelids blink periodically.ANS: C 6. A nurse assessing a patient who had a cerebrovascular accident involving the Broca area suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient?a. The patient understands speech but is unable to translate ideas into meaningful speech.b. The patient is unable to comprehend speech and thus does not respond verbally.c. The patient is able to understand speech but has difficulty forming words, creating muffled speech.d. The patient is unable to comprehend speech and responds inappropriately to conversation.ANS: A 7. The nurse hears in a report that a patient has receptive or fluent aphasia. What communication abilities does the nurse anticipate from this patient?a. The patient understands speech but is unable to translate ideas into meaningful speech.b. The patient is able to understand speech but has difficulty forming words creating muffled speech.c. The patient is unable to comprehend speech and thus does not respond verbally.d. The patient is emotionally liable and cries easily, which interferes with the ability to communicate.ANS: C 8. What is the earliest and most sensitive indication of altered cerebral function?a. Unequal pupilsb. Loss of deep tendon reflexesc. Paralysis on one side of the bodyd. Change in level of consciousnessANS: D 9. A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the cranial nerve related to swallowing?a. Ask the patient about feeling the blunt end of a paper clip along the jaw line.b. Observe the rising of the soft palate when the patient says Ahh.c. Observe the symmetry of the face when the patient talks.d. Assess taste on the anterior part of the tongue.ANS: B 10. A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve?a. Ask the patient to stick out the tongue and move it in all directions.b. Ask the patient to move the head to the right and left.c. Observe the symmetry of the face when the patient talks.d. Assess for taste on the anterior part of the tongue.ANS: A 11. In assessing a patients deep tendon reflexes, a nurse finds a patient has a 4+ triceps response. How does the nurse interpret this finding?a. A hyperactive responseb. A diminished responsec. An absent responsed. An expected responseANS: A 12. The nurse holds the patients relaxed arm with elbow flexed at a 90-degree angle, places a thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. Which deep tendon reflex is the nurse assessing?a. Brachioradialisb. Bicepsc. Tricepsd. DeltoidANS: B 13. A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?a. Diminished to absent pronation of the armb. Diminished to absent flexion of the elbowc. Diminished to absent extension of the elbowd. Diminished to absent adduction of the upper armANS: C 14. A nurse holds the patients relaxed left arm, with elbow flexed at a 90-degree angle, in one hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with either end of the reflex hammer. What is the expected response for this deep tendon reflex?a. Flexion of the left elbowb. Pronation of the left forearmc. Supination of the left armd. Extension of the left elbowANS: D 15. A nurse holds the patients relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. What is the expected response for this deep tendon reflex?a. Flexion of the left elbowb. Pronation of the left forearmc. Supination of the left armd. Extension of the left elbowANS: D 16. How does a nurse test the brachioradial deep tendon reflex?a. Uses the end of the handle on the reflex hammer to stroke the lateral aspect of the sole of the patients foot from heel to ballb. Asks the patient to slightly pronate the relaxed forearm into the nurses hand and strikes the appropriate tendon with the reflex hammerc. Holds the patients relaxed arm with the elbow flexed at a 90-degree angle in one hand, and palpates and strikes the appropriate tendon just above the elbow with the flat end of the reflex hammerd. Holds the patients relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammerANS: B 17. A nurse dorsiflexes a patients right ankle 90 degrees and then uses a reflex hammer to strike the appropriate tendon. What is the expected response for this deep tendon reflex?a. Extension of the right lower legb. Plantar flexion of the right toesc. Dorsiflexion of the right footd. Plantar flexion of the right footANS: D 18. The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and lower jaw to test the function of which cranial nerve?a. CN IV (trochlear nerve)b. CN V (trigeminal nerve)c. CN VI (abducens nerve)d. CN VII (facial nerve)ANS: B 19. A nurse who is assessing a patients eyes finds that the pupils are equal, round, and react to light and accommodation (PERRLA). These findings verify the expected functioning of which cranial nerve?a. Optic cranial nerve (CN II)b. Oculomotor cranial nerve (CN III)c. Trochlear cranial nerve (CN IV)d. Abducens cranial nerve (CN VI)ANS: B 20. In assessing a patient with a tumor in the pons, the nurse expects to find which abnormalities due to pressure on cranial nerves?a. Dilated pupils and ptosisb. Facial asymmetry and impaired hearingc. Difficulty swallowingd. Impaired gag reflexANS: B 21. The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex?a. Corneal reflexb. Gag reflexc. Blink reflexd. Cough reflexANS: B 22. Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move it side to side?a. Vagus nerve (CN X)b. Facial nerve (CN VII)c. Abducens nerve (CN VI)d. Hypoglossal nerve (CN XII)ANS: D 23. As a patient is walking down the hall, the nurse notices the patients staggering, unsteady gait. What findings does the nurse anticipate on the neurologic examination?a. When the patient stands with feet together, eyes open and then closed, an upright posture is maintained.b. When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers.c. When the patient is giving a history to the nurse, a tremor is noticed as the patients hands rest in the lap.d. When lying supine, the patient is able to move the heel of one foot down the shin of the other leg.ANS: B 24. A nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates an expected cerebellar function?a. Sways slightly and maintains upright posture with feet togetherb. Is unable to stand upright after turning around in a circle oncec. Steps sideways when standing with feet together and eyes closedd. Has to move arms horizontally to maintain balanceANS: A 25. The nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates a problem in the cerebellum?a. Maintains balance when eyes are open, but loses balance with eyes closedb. Is unable to stand upright after turning around in a circle oncec. Steps sideways when standing with feet together and eyes closedd. Sways slightly and maintains upright posture with feet togetherANS: C 26. What is the patients expected response when the nurse is assessing graphesthesia?a. Lies supine and runs one heel along the opposite shinb. Identifies a familiar object placed in the handsc. Describes where a sensation of a vibrating tuning fork is feltd. Identifies a letter or number drawn in the handANS: D 27. What is the patients expected response when the nurse is assessing stereognosis?a. Identifies an object placed in the handb. Distinguishes numbers or letters traced in the palm of the handc. Touches the index finger of the nondominant hand to the nosed. Walks heel to toe in a straight lineANS: A 28. A nurse correlates a patients altered stereognosis with a neurologic dysfunction in which part of the nervous system?a. Midbrain or ponsb. Temporal lobe or ascending nerve tractsc. Frontal lobe or motor nerve tractsd. Parietal lobe or sensory nerve tractsANS: D 29. Which part of the nervous system is a nurse assessing when he places a vibrating tuning fork on a patients wrist or ankle?a. Frontal lobe and motor tractsb. Parietal lobe and sensory tractsc. Hypothalamus and sensory tractsd. Cerebellum and motor tractsANS: B 30. A patient has a herniated disk compressing the lumbar spine at L2, L3, and L4 that is impairing deep tendon reflexes. Which response does a nurse expect from this patient?a. Diminished contraction of the gastrocnemius muscle with plantar flexion of the footb. Diminished contraction of the quadriceps muscle with extension of the lower legc. Diminished plantar flexion of the toesd. Diminished dorsiflexion of the foot and flexion of the toesANS: B 31. What technique does the nurse use to test the patellar deep tendon reflex?a. Using the end of the handle on the reflex hammer, the nurse strokes the lateral aspect of the sole of the patients foot from heel to ball.b. Ask the patient to flex one knee to 90 degrees, while the nurse dorsiflexes the ankle and strikes the appropriate tendon on the foot with the flat end of the reflex hammer.c. Ask the patient to flex one knee to 45 degrees, while the nurse plantar flexes the ankle and strikes the appropriate tendon of the ankle with the pointed end of the reflex hammer.d. Ask the patient to flex one knee to 90 degrees, while the nurse strikes the appropriate tendon in the knee with the blunt end of the reflex hammer.ANS: D 32. What technique does the nurse use to test ankle clonus?a. Strokes the lateral aspect of the sole of the patients foot from heel to ball with a reflex hammerb. Supports the patients knee in flexed position and sharply dorsiflexes the foot and maintains the flexionc. Plantar flexes the ankle and strikes the appropriate tendon of the ankle with the hammerd. Everts the ankle and slowly moves the ankle into plantar flexion and quickly release the footANS: B 33. Which response does a nurse expect when testing ankle clonus of a healthy woman?a. No movement of the footb. Plantar flexion of the footc. Extension of the lower legd. Dorsiflexion of the footANS: A MULTIPLE RESPONSE 1. To complete a symptom analysis, which questions does a nurse ask patient who recently had a seizure for the first time? Select all that apply.a. Did you have any warning signs before the seizure started?b. Did you lose consciousness during the seizure?c. Did the room seem to be spinning around before the seizure?d. Did you urinate during the seizure?e. What did you hear while you were seizing?f. How did you feel after the seizure?ANS: A, B, D, FCorrect: These are all appropriate questions to ask to gather more data about this patients first seizure.Incorrect: Did the room seem to be spinning around before the seizure? This question is about vertigo, which does not relate to this patient. What did you hear while you were seizing? The answer to this question is not needed in the data for this patient. DIF: Cognitive Level: Analyze REF: 345TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. Which characteristics are risk factors for cerebrovascular accident? Select all that apply.a. Excessive alcohol intakeb. Smokingc. Eating large amounts of smoked foodsd. Obesitye. Atherosclerosisf. High blood pressureANS: A, B, D, E, FCorrect: All of these are risk factors for cerebrovascular accident.Incorrect: Eating large amounts of smoked foods is a risk factor for stomach cancer. DIF: Cognitive Level: Remember REF: 362TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems 3. Which manifestations does a nurse correlate with a patient with suspected meningitis? Select all that apply.a. Ptosisb. Loss of balance when standing with feet together and the eyes closedc. Confusion, agitation, and irritabilityd. Severe headachee. Stiff neckf. LethargyANS: C, D, E, F

Skin, Hair, and Nails

1. A patient asks the nurse if it is possible to grow new skin. What is the nurses most appropriate response?a. Even if new skin growth is required, the melanocytes do not regenerate.b. The avascular epidermis sheds slowly and is replaced completely every 4 weeks.c. The outer layer of skin remains the same over the lifetime except for repairing injuries.d. Epidermal regeneration is impossible because it is avascular.ANS: B 2. A nurse assessing a patient with liver disease expects to find which manifestation during the examination?a. Yellowish color in the axilla and groinb. Yellow pigmentation in the sclerac. Very pale skin on the palmsd. Ashen-gray color in the oral mucous membranesANS: B 3. How does the nurse recognize jaundice in a dark-skinned patient?a. Inspect the conjunctiva for ashen-gray color.b. Inspect the nail beds for a deeper brown or purple skin tone.c. Inspect the palms and soles for yellowish-green color.d. Inspect the oral mucous membrane for yellow color.ANS: C 4. What signs of cyanosis does a nurse inspect for in a dark-skinned patient?a. Ashen-gray color of the oral mucous membranesb. Blue color in the nail bedsc. Ashen-blue color in the palms and solesd. Blue-gray color in the ear lobes and lipsANS: A 5. When the patients chart includes a notation that petechiae are present, what finding does a nurse expect during inspection?a. Purplish-red pinpoint lesionsb. Deep purplish or red patches of skinc. Small raised fluid-filled pinkish nodulesd. Generalized reddish discoloration of an area of skinANS: A 6. When performing a skin assessment of an adult patient, the nurse expects what finding?a. Reddened area does not blanch when gentle pressure is appliedb. Indentation of the finger remains in the skin after palpationc. Flaking or scaling of the skind. Return of skin to its original position when pinched up slightlyANS: D 7. A nurse notices a patients nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient?a. Pale conjunctivab. Jaundicec. Ecchymosisd. RashesANS: A 8. A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurses most appropriate response to this patient?a. This is simple vellus hair and it will decrease in amount over time.b. Some women in your cultural group normally have dark hair on their faces.c. This is unusual; female hair distribution should be limited to arms, legs, and pubis.d. Coarse dark hair could result from hormonal changes such as from menopause.ANS: D 9. What findings does a nurse expect when inspecting and palpating a patients nails?a. A nail base angle of not more than 90 degreesb. Whitish to clear nails in darker-skinned patientsc. Nail surface is smooth and roundedd. Transverse depression running across the nailsANS: C 10. A nurse notices that the angle of the patients proximal nail fold and the nail plate are almost a flat line; about 160 degrees. How does the nurse interpret this finding?a. This patient has chronic pulmonary disease.b. This is an expected finding.c. This is due to stress to the nails.d. This is associated with anemia.ANS: B 11. As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings?a. An expected findingb. Koilonychia (spoon nail)c. Clubbingd. LeukonychiaANS: C 12. While giving a history, a patient reports itching arms, legs, and chest after using a new soap. What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patients skin?a. Elevated irregularly shaped areas of edema of variable diameterb. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameterc. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluidd. Elevated, firm circumscribed areas less than 1 cm in diameterANS: A 13. While inspecting the skin, a nurse notices a lesion on the patients upper right arm. What is the best way to document the size of this lesion?a. Compare its size to the size of a coin.b. Estimate its size to the nearest inch.c. Use a centimeter ruler to measure the lesion.d. Trace the lesion onto a piece of paper.ANS: C 14. During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the patients skin, what finding will confirm the rash?a. Elevated, firm, well-defined lesions less than 1 cm in diameterb. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameterc. Elevated, fluid-filled lesions less than 1 cm in diameterd. Flat, well-defined, small lesions less than 1 cm in diameterANS: D 15. During inspection of a patients upper back, the nurse notices three small, elevated superficial lesions filled with purulent fluid. How does the nurse document this finding?a. As three cysts on the upper backb. As several bullae on the backc. As three pustules on the upper backd. As three wheals on the upper backANS: C 16. A nurse notices multiple lesions on a patients left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. What kind of primary lesions are these?a. Maculesb. Patchesc. Vesiclesd. BullaeANS: C 17. A nurse notices multiple lesions on the back of a patients left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. How does the nurse document these lesions?a. As multiple macules on the dorsum of the left handb. As multiple vesicles on the dorsum of the left handc. As several patches on the left handd. As several bullae on the dorsum of the left handANS: B 18. A patient has come to the clinic complaining of a bump behind his right ear. Upon inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider?a. Tumorb. Nodulec. Keloidd. PapuleANS: A 19. A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids?a. Roughened and thickened scales involving flexor surfacesb. Hypertrophic scarring extending beyond the original wound edgesc. Thin, fibrous tissue replacing normal skin following injuryd. Loss of the epidermal layer, creating a hollowed-out or crusted areaANS: B 20. A patient reports the mole on the scalp has started itching and it bleeds when scratching it. What other finding is a danger sign for pigmented skin lesions?a. Symmetry of the lesionb. Rounded borderc. Color variationd. Size less than 6 mm wideANS: C 21. A toddler patient has a small, slightly raised bright red area on the trunk. The childs mother reports that the lesion has been present since birth and has become a little larger. What type of lesion does the nurse suspect?a. Vascular nevib. Purpurac. Ecchymosisd. Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.ANS: D 22. A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from purpura?a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter.b. Ecchymosis does not blanch and purpura does blanch.c. Ecchymosis has raised lesions and purpura has flat lesions.d. Ecchymosis is irregularly shaped and purpura is round.ANS: A 23. A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion?a. As an angiomab. As purpurac. As petechiaed. As ecchymosisANS: D 24. A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patients left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage?a. Stage Ib. Stage IIc. Stage IIId. Stage IVANS: B 25. A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes? What explanation does the nurse give the patient about the cause of this skin disorder?a. Your itching is caused by a bacterial infection.b. Your itching is caused by an allergic reaction.c. Your itching is caused by a viral infection.d. Your itching is caused by a fungal infection.ANS: D 26. A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma?a. Nonblanching lesionb. Irregular borderc. Diameter less than 5 mmd. Black color of the lesionANS: B 27. During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer?a. Use a tanning booth instead of sunning outside if a tan is desired.b. Wear protective clothing while in the sun.c. Perform self-examination of skin monthly.d. Use sunscreen with a sun protection except on overcast days.ANS: B 28. A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of healing. What is the most appropriate action for the nurse at this time?a. Obtain further data now to rule out abuse.b. Remind parents that toddlers are clumsy and may fall, causing bruising.c. Determine if this toddler has a coagulation disorder.d. Recommend further observation at future visits.ANS: A MULTIPLE RESPONSE 1. What findings does the nurse expect when assessing skin, hair, and nails of a healthy male adult? Select all that apply.a. Transverse depression noticed across nailsb. Scalp is baldc. Elevated, firm, circumscribed area less than 1 cm wide found on the fingersd. Purpura and ecchymosis are noticed on arms and legse. Freckles are noted on face, back, arms, and legsf. Skin turgor is elasticANS: B, E, FCorrect:Scalp is bald; freckles are noted on face, back, arms and legs; and skin turgor is elastic . These are expected findings for a healthy adult male. Incorrect: Transverse depression across the nails describes Beau lines. It results from a stressor that temporarily impairs nail formation. An elevated, firm, circumscribed area, less than 1 cm wide on the fingers describes a papule, such as a wart. Purpura and ecchymosis on arms and legs are indications of bleeding. DIF: Cognitive Level: Analyze REF: 106-107| 119TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? Select all that apply.a. When did the rash first start?b. Do you have a family history of rashes?c. What makes the rash worse?d. What do you do to make your rash better?e. Describe the sensation from the rash, does it burn or itch?f. Describe what the rash looked like initially.ANS: A, C, D, E, F

Head and nose and throat

1. A patient is admitted with edema of the occipital lobe following a head injury. The nurse correlates which finding with damage to this area? a. Ipsilateral ptosis b. Impaired visionc. Pupillary constrictiond. Increased intraocular pressureANS: B FeedbackA Ipsilateral ptosis (drooping of the eye lid) is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. The nurse must correlate anatomy with function and assessment.B The occipital lobe contains the visual context.C Pupillary constriction is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain.D This abnormality is associated with glaucoma rather than injury to the occipital lobe.DIF: Cognitive Level: Analyze REF: 138TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches?a. I usually have nausea and vomiting with my headaches.b. My whole head is constantly throbbing.c. It feels like my head is in a vice.d. The pain is on the left side over my eye, forehead, and cheek.ANS: D FeedbackA This is descriptive of migraines rather than cluster headaches.B This is descriptive of migraines rather than cluster headaches.C This is descriptive of tension rather than cluster headaches.D This description is consistent with cluster headaches.DIF: Cognitive Level: Apply REF: 144TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 3. A patient reports having migraine headaches on one side of the head that often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which associated symptoms of migraine headaches?a. Nausea, vomiting, or visual disturbancesb. Nasal stuffiness or dischargec. Ringing in the ears or dizzinessd. Red, watery eyes or drooping eyelidsANS: A FeedbackA These are symptoms associated with migraine headaches.B This is a symptom associated with cluster headaches rather than migraine headaches.C These symptoms are not associated with migraine headaches.D These are symptoms associated with cluster headaches rather than migraine headaches.DIF: Cognitive Level: Analyze REF: 144TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 4. The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches?a. I usually have nausea and vomiting with my headaches.b. My whole head is constantly throbbing.c. It feels like my head is in a vice.d. The pain is on the left side over my eye, forehead, and cheek.ANS: C FeedbackA This is descriptive of migraines rather than tension headaches.B This is descriptive of migraines rather than tension headaches.C This is descriptive of tension headaches, which is consistent with the rest of the data reported by the patient.D This is consistent with cluster headaches rather than tension headaches.DIF: Cognitive Level: Apply REF: 144TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 5. During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?a. I felt faint, like I was going to pass out.b. I just could not keep my balance when I sat up.c. It seemed that the room was spinning around.d. I was afraid that I was going to lose consciousness.ANS: C FeedbackA This is a description of lightheadedness, a form of dizziness.B This is a description of disequilibrium, a form of dizziness.C This is consistent with vertigo because it includes a sensation of motion.D This is a description of syncope, a form of dizziness.DIF: Cognitive Level: Analyze REF: 144TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 6. During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?a. I felt faint, like I was going to pass out.b. It felt like I was on a merry-go-round.c. The room seemed to be spinning around.d. My body felt like it was revolving and could not stop.ANS: A FeedbackA This is a description of lightheadedness, a form of dizziness.B This is consistent with objective vertigo because it includes a sensation of motion.C This is consistent with objective vertigo because it includes a sensation of motion.D This is consistent with subjective vertigo because it includes a sensation of ones body rotating in space.DIF: Cognitive Level: Analyze REF: 144-145TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 7. Which patient in the eye clinic should the nurse assess first?a. The patient who reports a gradual clouding of visionb. The patient who complains of sudden loss of visionc. The patient who complains of double visiond. The patient who complains of poor night visionANS: B FeedbackA A gradual clouding of vision is a symptom of cataracts that develop slowly and do not require immediate assessment.B Sudden vision loss may indicate a detached retina and requires immediate referral.C Double vision is a symptom of cataracts that develop slowly and do not require immediate assessment.D Poor night vision is a symptom of cataracts that develop slowly and do not require immediate assessment.DIF: Cognitive Level: Apply REF: 144-145TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 8. A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patients ears?a. Redness and edema of the pinna of the right earb. Report of pain when the nurse manipulates the right earc. Bulging and red tympanic membrane in the right eard. Increased cerumen in the right ear canalANS: C FeedbackA Redness and edema of the pinna of the right ear is consistent with external ear pain that may be associated with otitis externa or swimmers ear.B Report of pain when the nurse manipulates the right ear is consistent with external ear pain that may be associated with otitis externa or swimmers ear.C Bulging and red tympanic membrane in the right ear is consistent with internal ear pain that may be associated with otitis media.D Increased cerumen in the right ear canal is not consistent with internal ear pain.DIF: Cognitive Level: Apply REF: 145| 165TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 9. During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares?a. Enlarged and pale turbinatesb. Polyps within the naresc. High vascularity of the turbinatesd. Dry and dull turbinatesANS: A FeedbackA Enlarged and pale turbinates are expected findings for allergic rhinitis.B Polyps within the nares is not an expected finding.C High vascularity of the turbinates is not an expected finding.D Dry and dull turbinates is not an expected finding.DIF: Cognitive Level: Apply REF: 145-146| 186TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 10. A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination?a. Foul-smelling drainageb. Purulent green-yellow drainagec. Bloody drainaged. Watery drainageANS: B FeedbackA Foul-smelling drainage is consistent with a foreign object in the nose.B Purulent green-yellow drainage is consistent with a nasal or sinus infection.C Bloody drainage is consistent with trauma to the nose.D Watery drainage is consistent with a nasal allergy.DIF: Cognitive Level: Apply REF: 145TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 11. A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patients nares?a. Clearb. Malodorousc. Yellowd. GreenANS: A FeedbackA The patient has allergic rhinitis, which produces clear drainage.B Malodorous drainage is associated with bacterial infection, which is not consistent with the history given by this patient.C Yellow drainage is associated with bacterial infection, which is not consistent with the history given by this patient.D Green drainage is associated with bacterial infection, which is not consistent with the history given by this patient.DIF: Cognitive Level: Apply REF: 145TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 12. A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose?a. Deviated septumb. Pale turbinatesc. Perforated nasal septumd. Localized erythema and edemaANS: C FeedbackA Deviated septum may be from birth or trauma to the nose, but not from cocaine use.B Pale turbinates are an indication of allergies.C Perforated nasal septum develops from cocaine use.D Localized erythema and edema are nonspecific and indicate inflammation somewhere in the nose.DIF: Cognitive Level: Apply REF: 170TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 13. While taking a history, the nurse observes that the patients facial cranial nerves (CN VII) are intact based on which behaviors of the patient?a. The patients eyes move to the left, right, up, down, and obliquely during conversation.b. The patient moistens the lips with the tongue.c. The sides of the mouth are symmetric when the patient smiles.d. The patients eyelids blink periodically.ANS: C FeedbackA This represents movement of the extraocular muscles, which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI, respectively).B This represents movement of the tongue, which is controlled by the hypoglossal cranial nerve (CN XII).C This represents facial symmetry, which is controlled by the facial cranial nerve (CN VII).D This represents function of the oculomotor cranial nerve (CN III).DIF: Cognitive Level: Apply REF: 137| 171TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 14. To assess jaw movement of an adult patient, the nurse uses which technique?a. Asking the patient to open the mouth and then passively moving the patients open jaw from side to sideb. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouthc. Asking the patient to open the mouth and to resist the nurses attempt to close the mouthd. Using the pads of all fingers to feel along the mandible for tenderness and nodulesANS: B FeedbackA The patients jaw movement should be active, not passive.B This is the correct technique for palpating the jaw.C This technique assesses strength of the jaw, which is not typically evaluated.D Palpating under the middle of the mandible may reveal the submental lymph node.DIF: Cognitive Level: Apply REF: 149TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 15. The nurse palpates the patients jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw?a. Clinch the jaws together as tightly as possible.b. Move the lower jaw from side to side.c. Open the mouth as wide as possible, like a yawn.d. Move the lower jaw forward and backward several times.ANS: B FeedbackA This is not an assessment technique for the jaw.B This is the technique to complete assessment of the motion of the jaw.C This was completed when the nurse asked the patient to open and close the mouth.D This is not an assessment technique for the jaw.DIF: Cognitive Level: Apply REF: 149TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 16. A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time?a. Auscultate the temporal arteries for bruits.b. Palpate the arteries with the patient in supine position.c. Document this as an expected finding.d. Measure the patients blood pressure.ANS: C FeedbackA This is not necessary for this patient at this time.B This is not necessary for this patient at this time.C These are consistent with expected assessment.D This will be done as a part of the assessment, but does not relate to the expected palpation of this patients temporal arteries.DIF: Cognitive Level: Apply REF: 149TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 17. What instructions does the nurse give the patient before using the Snellen visual acuity chart?a. Remove your eyeglasses before attempting to read the lowest line.b. Stand 10 feet from the chart and read the first line aloud.c. Hold a white card over one eye and read the smallest possible line.d. Squint if necessary to improve the ability to read the largest letters.ANS: C FeedbackA Patients should wear their glasses when visual acuity is tested.B The patient should stand 20 feet from the Snellen chart.C This is the appropriate technique for using the Snellen chart.D The patient should not squint to see the chart.DIF: Cognitive Level: Understand REF: 149TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 18. Which cranial nerve is assessed by using the Snellen visual acuity chart?a. Optic cranial nerve (CN II)b. Oculomotor cranial nerve (CN III)c. Abducens cranial nerve (CN IV)d. Trochlear cranial nerve (CN VI)ANS: A FeedbackA The optic cranial nerve (CN II) provides vision tested by the Snellen visual acuity chart.B CN III controls pupillary constriction, eyelid movement, and eyeball movement.C CN IV controls eyeball movement.D CN VI controls eyeball movement.DIF: Cognitive Level: Apply REF: 138| 150TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 19. Which finding on assessment of a patients eyes should the nurse document as abnormal?a. An Asian American patient with an upward slant to the palpebral fissureb. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the irisc. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbusd. An American Indian patient whose pupillary diameters are 5 mm bilaterallyANS: B FeedbackA An Asian American patient with an upward slant to the palpebral fissure has an expected racial variation.B A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris has eyeball protrusion beyond the supraorbital ridge, which indicates exophthalmos caused by hyperthyroidism.C An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus has an expected racial variation.D An American Indian whose pupils are 5 mm bilaterally is an expected finding.DIF: Cognitive Level: Understand REF: 151TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 20. A nurse shines a light toward the bridge of the patients nose and notices that the light reflection in the right cornea is at the 9 oclock position and in the left cornea at the 9 oclock position. What is the interpretation of this finding?a. The extraocular muscles of both eyes are intact.b. The cornea of each eye is transparent.c. The sclera of each eye is clear.d. The consensual reaction of both eyes is intact.ANS: A FeedbackA The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric.B The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric.C The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric.D Consensual reaction involves constriction of pupils.DIF: Cognitive Level: Apply REF: 153TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 21. How does a nurse assess movements of the eyes?a. By assessing peripheral visionb. By noting the symmetry of the corneal light reflexc. By assessing the cardinal fields of gazed. By performing the cover-uncover testANS: C FeedbackA This tests the function of cranial nerve I (optic).B This indicates symmetry of eye muscles.C This tests the movement of the eye in all directions, which assesses the functions of the cranial nerves III (oculomotor), IV (abducens), and VI (trochlear).D This is performed after the corneal light reflex is abnormal, indicating asymmetric eye muscles.DIF: Cognitive Level: Understand REF: 154-156TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 22. On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding?a. As an indication of a type of anemiab. As a hordeolum or styc. As jaundiced. As an expected racial variationANS: D FeedbackA This may cause a pale conjunctiva.B This is an acute infection originating in the sebaceous gland of the eyelid.C Jaundice is a yellow color of the sclera associated with liver or gallbladder disease.D This as an expected racial variation.DIF: Cognitive Level: Remember REF: 153TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 23. A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action?a. Document this finding as an abnormal finding.b. Assess the patient for accommodation.c. Document this finding as a consensual reaction.d. Assess the patients corneal light reflex.ANS: C FeedbackA This is a description of an expected findingconsensual reaction.B Accommodation is not assessed in response to consensual reaction; it tests the function of the oculomotor cranial nerve (CN III).C This is a description of expected consensual reaction.D This item describes a consensual reaction rather than a corneal light reflex.DIF: Cognitive Level: Apply REF: 154TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 24. When inspecting a patients eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve?a. Pupillary constriction to lightb. Visual acuityc. Peripheral visiond. Presence of the red reflexANS: A FeedbackA Cranial nerve III (oculomotor) controls pupillary dilation and constriction, as well as eyelid movement. Pupil dilation and ptosis may occur when CN III is impaired.B Cranial nerve II (optic) provides vision.C Cranial nerve II (optic) provides peripheral vision.D The red reflex is not controlled by cranial nerve III, but is created by a light illuminating the retina.DIF: Cognitive Level: Apply REF: 154TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 25. How does a nurse recognize normal accommodation?a. The patient has peripheral vision of 90 degrees left and right.b. The patients eyes move up and down, side to side, and obliquely.c. The right pupil constricts when a light is shown in the left pupil.d. The patients pupils dilate when looking toward a distant object.ANS: D FeedbackA Normally a patient has 90 degrees peripheral vision temporally, but only 60 degrees nasally.B This is an expected finding, but is not a test for accommodation. It is a test of extraocular muscle function in the six cardinal fields of gaze.C This is an expected finding for consensual reaction, rather than accommodation.D This is an indication of accommodation.DIF: Cognitive Level: Understand REF: 154TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 26. How does a nurse recognize a patients mydriasis?a. The lens of each of the patients eyes is opaque.b. There is involuntary rhythmical, horizontal movement of the patients eyes.c. There is a white opaque ring encircling the patients limbus.d. The patients pupils are 7 mm and do not constrict.ANS: D FeedbackA An opaque lens is an abnormality that occurs when cataracts are present.B An involuntary rhythmical, horizontal movement of the patients eyes is a description of nystagmus.C A white opaque ring encircling the patients limbus is a description of corneal arcus seen in patients older than 60 years of age.D Mydriasis is pupil size greater than 6 mm and the pupil fails to constrict.DIF: Cognitive Level: Understand REF: 154TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 27. A nurse uses which technique to assess a patients peripheral vision?a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurses finger as it moves side to side, up and down, and obliquely.b. The nurse covers one of the patients eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement.c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen.d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.ANS: C FeedbackA This technique tests extraocular muscle symmetry.B This cover-uncover technique is performed when the corneal light reflex is asymmetric.C This is the confrontation test that tests peripheral vision.D This describes the corneal light reflex that tests the symmetry of the eye muscles.DIF: Cognitive Level: Apply REF: 150TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 28. During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patients covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patients eyes?a. Symmetry of extraocular musclesb. Visual acuity in the uncovered eyec. Peripheral vision of the uncovered eyed. Consensual reaction of the uncovered eyeANS: C FeedbackA Symmetry is tested by the corneal light reflex.B Visual acuity is tested using the Snellen chart.C This describes the confrontation test, which assesses peripheral vision.D Consensual reaction is tested by noticing the pupillary constriction of one eye when a light is being shown into the other eye.DIF: Cognitive Level: Apply REF: 156TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 29. During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patients eyes. How does a nurse document this finding?a. An expected racial variationb. Nystagmusc. Exophthalmusd. MyopiaANS: B FeedbackA This is not a racial variation.B An involuntary rhythmical, horizontal movement of the patients eyes is a description of nystagmus.C Exophthalmus is the bulging of the eyeball forward, seen in patients with hyperthyroidism.D Myopia is an elongated eyeball found in patients who are nearsighted.DIF: Cognitive Level: Understand REF: 156TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 30. A nurse shines a light toward the bridge of the patients nose and notices that the light reflection in the right cornea is at the 2 oclock position and in the left cornea at the 10 oclock position. Based on these data, the nurse should take what action?a. Document these findings as normal.b. Perform the cover-uncover test.c. Perform the confrontation test.d. Document these findings as abnormal.ANS: B FeedbackA The findings are abnormal. The light should appear in the same location in each cornea.B The nurse is performing the corneal light reflex test and the findings are abnormal. Thus, when the corneal light reflex is asymmetric, the cover-uncover test is performed to determine which eye has the weak extraocular muscle(s).C The confrontation test is used to assess peripheral visual fields and is not appropriate to perform when the corneal light reflex is asymmetric.D The asymmetric corneal light reflex is abnormal, but the cover-uncover test should follow the abnormal finding to determine which eye has the weak extraocular muscle(s).DIF: Cognitive Level: Analyze REF: 153TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 31. During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patients eyes?a. Anterior chamber depth is shallow.b. Red reflex is absent.c. Extraocular muscle movement is asymmetric.d. Retinal arteries are wider than retinal veins.ANS: B FeedbackA Shallow anterior chamber depth occurs in glaucoma.B The symptoms suggest cataracts. The red reflex cannot be seen because the light cannot penetrate the opacity of the lens.C Extraocular muscle movement is asymmetric. Cataracts affect the lens rather than the eye muscles.D Retinal arteries are wider than retinal veins. Cataracts affect the lens rather than the retinal vessels.DIF: Cognitive Level: Analyze REF: 158| 184TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 32. What changes in using the ophthalmoscope should the nurse need to make when inspecting the eye of a patient who is nearsighted?a. Holding the ophthalmoscope in the right hand when inspecting the patients right eyeb. Using the grid light of the lens aperture to visualize the internal structures of the eyec. Rotating the diopter to the red (minus) numbersd. Asking the patient to look directly into the ophthalmoscope lightANS: C FeedbackA This procedure is performed with all patients having an internal eye examination.B The grid is used to estimate the size of lesions.C This compensates for the longer eyeball of a myopic patient.D This is an instruction given to the patient to visualize the macula.DIF: Cognitive Level: Apply REF: 158TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 33. After seeing the red reflex and retinal vessels through the ophthalmoscope, how does the nurse locate the optic disc?a. By rotating the diopter to the block (positive) numbers until the optic disc comes into focusb. By following the retinal vessels inward toward the nose until optic disc is seenc. By using the green beam light while looking outward toward the ear until the disc is seend. By locating the macula and then looking temporally (toward the ear) until the disc is seenANS: B FeedbackA This procedure is used for patients who are myopic.B This procedure locates the optic disc.C The green beam is used to identify retinal hemorrhages.D The macula lies temporal to the optic disc; thus the optic disc is in the opposite direction.DIF: Cognitive Level: Apply REF: 158-159TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 34. When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish the retinal arteries from the retinal veins?a. The arteries are narrower than veins.b. The arteries are a darker red than veins.c. The arteries have no light reflex and the veins have a narrow band of light in the center.d. The arteries have prominent pulsations and veins have no pulsations.ANS: A FeedbackA The artery-to-vein width should be 2:3 to 4:5.B Arteries are lighter red than veins.C Arteries have a narrow band of light in the center and veins have no light reflex.D Arteries show little to no pulsations and venous pulsations may be visible.DIF: Cognitive Level: Understand REF: 159TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 35. Which finding warrants a referral for additional evaluation?a. Earlobes hanging freely from the base of the pinnab. Ears having painless nodules less than 1 cm in diameter at the helixc. Ears measuring 8 cm in lengthd. Pinna is 20 degrees lower than the outer canthus of the eyeANS: D FeedbackA Earlobes hanging freely from the base of the pinna is an expected finding.B This is called a Darwin tubercle. It is a normal deviation and may be noted at the helix of the ear.C A length of 8 cm is an expected finding.D The pinna of the ear should align directly with the outer canthus of the eye and be angled no more than 10 degrees from a vertical position.DIF: Cognitive Level: Apply REF: 160TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 36. A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection?a. Tinnitus, vertigo, and dizzinessb. Clear drainage from the ear and nosec. Loss of hearing and smelld. Purulent drainage from the ear and bloody drainage from the noseANS: B FeedbackA These are subjective and gathered during the history rather than inspection. Although the patient may report having dizziness or vertigo, the finding of tinnitus is inconsistent with a basilar skull fracture.B This may occur after a basilar skull fracture. The clear drainage may be cerebrospinal fluid.C This is inconsistent with a basilar skull fracture.D Purulent drainage is inconsistent with a basilar skull fracture, and bloody drainage usually does not come from the nose, but may be seen from the ear.DIF: Cognitive Level: Analyze REF: 162TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 37. An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspect this patients auditory canal?a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal.b. Remove cerumen from each canal before inserting otoscope.c. Choose the smallest otoscope speculum that will fit the patients ear comfortably.d. Pull the pinna slightly downward and backward before inserting the otoscope speculum.ANS: A FeedbackA This is the correct technique.B Removing cerumen is not necessary.C The largest speculum that comfortably fits in the ear canal is the one that should be chosen.D For adults, the pinna is pulled up and backward to straighten the ear canal.DIF: Cognitive Level: Apply REF: 162TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 38. A nurse examines a patients auditory canal and tympanic membrane with an otoscope and observes which finding as normal?a. Clear fluid lining the auditory canalb. A firm tympanic membrane without fluctuation with puffs of airc. A small hole within the cone of lightd. A shiny, translucent tympanic membraneANS: D FeedbackA Clear fluid or bloody drainage following a head injury may indicate a basilar skull fracture.B An expected response is that the tympanic membrane slightly fluctuates with puffs of air.C A cone of light is expected, but a hole indicates perforation.D A shiny, translucent tympanic membrane is an expected finding.DIF: Cognitive Level: Apply REF: 164TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 39. A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse?a. Instructing the patient to cover the ear not being testedb. Standing beside the patient on the side of the ear being testedc. Shielding the mouth to prevent the patient from reading lipsd. Whispering one or two syllable words and ask the patient to repeat what is heardANS: B FeedbackA This is the correct technique.B The student nurse should stand 1 to 2 feet in front or to the side of the patient.C This is the correct technique.D This is the correct technique.DIF: Cognitive Level: Apply REF: 165TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 40. A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patients tympanic membrane to appear?a. Dullb. Shinyc. Redd. Blue to deep redANS: C FeedbackA This indicates fibrosis or scarring.B This is normal for the tympanic membrane.C This indicates infection in the middle ear, such as otitis media.D This indicates blood behind the tympanic membrane, which may have occurred secondary to injury.DIF: Cognitive Level: Apply REF: 145| 163TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 41. During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse?a. Repeat the test again using a 2000 Hz tuning fork.b. Tell the patient that this represents an expected finding.c. Refer the patient for additional testing to detect hearing abnormality.d. Perform a Weber test to confirm the findings of the Rinne test.ANS: B FeedbackA This is unnecessary because the finding of the Rinne test was normal.B This is a normal finding. Air conduction (30 seconds) is twice as long as bone conduction (15 seconds).C This is unnecessary because the finding of the Rinne test was normal.D This is unnecessary because the finding of the Rinne test was normal.DIF: Cognitive Level: Analyze REF: 166TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 42. During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test?a. Air conduction will be twice as long as bone conduction (2:1 ratio).b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio).c. Bone conduction will be longer than air conduction.d. Bone conduction will be equal to air conduction.ANS: C FeedbackA This is an expected finding.B This finding is consistent with a sensorineural hearing loss, but this patient has a conduction hearing loss based on the results of the Weber test.C This finding from the Rinne test indicates a conduction hearing loss, which is consistent with the finding from the Weber test described in the question.D This finding is not consistent with the conductive hearing loss described.DIF: Cognitive Level: Analyze REF: 166TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 43. Which finding indicates that this patient has a sensorineural hearing loss?a. The patient hears sound by air conduction longer than by bone conduction.b. The patient hears sound from a vibrating tuning fork in the affected ear only.c. The patient hears normal conversation at 40 dB and a whisper at 20 dB.d. The patient hears the rubbing of fingers together from a distance of 4 inches from each ear.ANS: A FeedbackA In the Rinne test, hearing sound from a vibrating tuning fork longer by air conduction than by bone conduction is consistent with a sensorineural hearing loss.B This finding from the Weber test is consistent with a conduction hearing loss.C This is an expected finding using audiometry.D This is an expected finding using the finger rubbing screening hearing test.DIF: Cognitive Level: Apply REF: 166TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 44. How does the nurse perform a Weber test to assess hearing function?a. Whispers three to four words into the patients ear and asks him to repeat the words heardb. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both earsc. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the soundsd. Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the soundANS: B FeedbackA This technique describes the whisper test.B This technique describes the Weber test.C This technique describes the use of an audiometer.D This technique describes part of the Rinne test.DIF: Cognitive Level: Apply REF: 166TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 45. How does the nurse perform a Rinne test of hearing function?a. Whispers several words to the patient and requests that the patient repeat the words heardb. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears or if it is louder in one ear than the otherc. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the soundsd. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears itANS: D FeedbackA This technique describes the whisper test.B This technique describes the Weber test.C This technique describes the use of an audiometer.D This technique describes the Rinne test.DIF: Cognitive Level: Apply REF: 167TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 46. A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing?a. Bone conduction will be longer than air conduction on the Rinne test (BC > AC).b. Air conduction will be longer than bone conduction on the Rinne test (AC > BC).c. Sound lateralizes to the affected ear on the Weber test.d. Sound lateralizes to both ears equally on the Weber test.ANS: B FeedbackA This finding indicates a conduction hearing loss, rather than a sensorineural hearing loss.B This finding indicates a sensorineural health loss, the most common cause of presbycusis.C This finding indicates a conduction hearing loss, rather than a sensorineural hearing loss.D This is a normal finding on this test.DIF: Cognitive Level: Analyze REF: 167-168TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 47. While taking a history, the nurse notices that the patients family member repeats most of the questions to the patient in a loud voice. Based on this information, what finding does the nurse anticipate when assessing this patients hearing using an audioscope?a. 5 dB hearing loss at all frequenciesb. 10 dB hearing loss at all frequenciesc. 20 dB hearing loss at all frequenciesd. 40 dB hearing loss at all frequenciesANS: D FeedbackA This decibel level is not tested by an audioscope .B A 10 dB loss in high frequencies results in difficulty hearing quiet sounds, such as a heartbeat.C A 20 dB loss in high frequencies results in difficulty hearing high-pitched consonants, such as a whisper.D A 40 dB loss in all frequencies causes moderate difficulty in hearing normal speech.DIF: Cognitive Level: Apply REF: 168TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 48. A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis?a. Unilateral foul-smelling drainageb. Bilateral purulent green-yellow dischargec. Bilateral bloody discharged. Unilateral watery dischargeANS: A FeedbackA This is consistent with presence of a foreign object in one side of the nose.B This is consistent with a nasal or sinus infection.C This is consistent with localized trauma, such as a nasal fracture.D This is consistent with a history of head injury and may indicate skull fracture.DIF: Cognitive Level: Apply REF: 162TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 49. In assessing a patient with head injury, the nurse should be most concerned with which finding?a. Pain on palpation of the scalpb. Unilateral clear, watery nasal dischargec. A scalp laceration at the sight of injuryd. Complaints of dizzinessANS: B FeedbackA This is expected after a head injury and is not a cause for concern.B This may be cerebrospinal fluid, indicating a skull fracture.C This is expected after a head injury and is not a cause for concern.D This is expected after a head injury and is not a cause for concern.DIF: Cognitive Level: Understand REF: 162TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 50. A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the nasal mucosa?a. Inserts a nasal speculum horizontally into the patients affected naresb. Inserts a nasal speculum obliquely into the patients affected naresc. Uses a light source from the ophthalmoscoped. Inserts a nasal speculum vertically into the patients affected naresANS: B FeedbackA Horizontal insertion puts pressure on the nasal septum, which is painful.B This is the appropriate technique for inspecting the nares.C The alternate light source is from an otoscope, rather than an ophthalmoscope. The otoscope has an ear speculum that can be used when a nasal speculum is unavailable.D Vertical insertion obstructs the nurses view of the internal nares.DIF: Cognitive Level: Understand REF: 169-170TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 51. When inspecting a patients nasal mucous membrane, which finding does the nurse expect to see?a. Deep pink turbinatesb. Red, edematous mucous membranesc. Septum that angles to the leftd. Clear exudateANS: A FeedbackA These are expected for a nasal inspection.B These indicate a local infection within the nose.C This is abnormal.D This occurs with nasal allergies.DIF: Cognitive Level: Understand REF: 170TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 52. A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the nurse uses transillumination to assess the sinuses and notes which finding indicating recovery from a frontal sinus infection?a. The soft palate illuminates brightly when the light source is placed against the lateral nose.b. No illumination is noted when the light source is placed firmly against the lateral nose.c. A bright glow illuminates the hard palate when the light source is placed against each temporal bone.d. A reddish light is noted above the eyebrows when the light is placed against each supraorbital rim.ANS: D FeedbackA This describes incorrect technique for transillumination.B An absence of a glow during transillumination of the sinuses may indicate that the sinuses are congested.C This describes incorrect technique for transillumination.D Finding a reddish light above the eyebrows when the light is placed against each supraorbital rim is consistent with frontal sinuses free of infection.DIF: Cognitive Level: Apply REF: 171TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 53. A nurse suspects the patient has an infection of the maxillary sinuses. How can this suspicion be confirmed?a. Using a flashlight to illuminate the floor of the mouthb. Pressing gently with both thumbs into the eyebrow ridgesc. Applying firm pressure with the thumbs below the cheekbonesd. Standing behind the patient and asking him or her to slowly rotate the headANS: C FeedbackA To transilluminate the maxillary sinuses, the nurse places the source of light lateral to the nose, just beneath the medial aspect of the eye, and looks through the patients open mouth for illumination of the hard palate.B This palpates the frontal sinuses rather than the maxillary sinuses.C This palpates the maxillary sinuses to detect tenderness, which may indicate sinus congestion or infection.D This is not a correct technique to confirm infection of the maxillary sinuses.DIF: Cognitive Level: Apply REF: 170TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 54. After assessment of the nose and paranasal sinuses, which finding requires further investigation by the nurse?a. Nasal septum off the midlineb. Nose in the midline of the facec. Middle turbinates deep pink in colord. Noiseless exchange of air from each narisANS: A FeedbackA A deviated septum is an abnormal finding that needs further investigation.B This is an expected finding.C This is a normal finding.D This is a normal finding.DIF: Cognitive Level: Understand REF: 170TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 55. When inspecting a patients posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal?a. Both tonsils have a smooth surface.b. Left and right tonsils meet at the midline.c. Left and right tonsils extend beyond the posterior pillars.d. Both tonsils have a glistening appearance.ANS: B FeedbackA A smooth surface is expected for the tonsils.B This indicates an enlargement documented as 4+.C This is an expected finding for the tonsils.D This is an expected finding for the tonsils.DIF: Cognitive Level: Apply REF: 174TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 56. Wearing gloves, the nurse grasps the patients tongue with a gauze pad and palpates a small, firm nodule on the left side of the tongue. Based upon this finding, what is the nurses appropriate response?a. Document that the patients tongue is normal on palpation.b. Inspect the left submandibular salivary glands for redness.c. Ask the patient to move the tongue in all directions.d. Palpate cervical and submental lymph nodes for enlargement.ANS: D FeedbackA The nodule is not an expected finding.B The salivary glands are not affected by a nodule of the tongue.C This assesses the hypoglossal cranial nerve or movement of the tongue, which is not related to the nodule found.D The nodules may indicate a malignancy of the tongue, which may also cause enlarged cervical or submental lymph nodes.DIF: Cognitive Level: Analyze REF: 175TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 57. A nurse assesses neck range of movement of several adults. Which patient has an expected range of motion of the neck?a. Patient A is unable to resist the nurses attempt to move the head upright.b. Patient B bends the head to the right and left (ear to shoulder) 15 degrees.c. Patient C flexes chin toward the chest 45 degrees.d. Patient D hyperextends the head 30 degrees from midline.ANS: C FeedbackA This finding is abnormal.B This finding is abnormal. The patient should be able to laterally bend the head 40 degrees from midline in each direction.C This is an expected finding.D The patient should be able to hyperextend the head 55 degrees from midline.DIF: Cognitive Level: Understand REF: 176TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 58. What technique does a nurse use when palpating the right lobe of a patients thyroid gland using the anterior approach?a. Pushes the cricoid process to the left with the right thumbb. Displaces the trachea to the right with the left thumbc. Manipulates the thyroid between the thumb and index fingerd. Moves the sternocleidomastoid muscle to the right with the left thumbANS: B FeedbackA This is not a correct technique.B This is the correct technique for palpating the thyroid gland using the anterior approach.C This is not a correct technique.D This is not a correct technique.DIF: Cognitive Level: Apply REF: 177TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 59. What technique does a nurse use when palpating the right lobe of a patients thyroid gland using the posterior approach?a. Pushes the cricoid process to the left with the right thumb and feels the right lobe with the left handb. Uses the left hand to push the sternocleidomastoid muscle to the right and feels the lobe with the right handc. Pushes the trachea to the right with the left hand and feels the right lobe with the right handd. Places the fingers on either side of the trachea above the cricoid cartilage and feels the right lobeANS: C FeedbackA This description is not a correct technique. In the posterior approach, the right lobe is felt with the right hand.B This description is not a correct technique. The trachea, not the muscle, is moved to the side.C This is the correct technique.D This description is not a correct technique. The fingers are placed below the cricoid cartilage.DIF: Cognitive Level: Apply REF: 177TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 60. What instruction does a nurse give a patient to facilitate palpation of the right lobe of the thyroid gland?a. Swallow for me one time.b. Flex your head down and to the left.c. Rotate your head to the right for me.d. Hold your breath for a few seconds.ANS: A FeedbackA The patient is asked to swallow to make the thyroid lobe easier to palpate.B This is incorrect to palpate the right lobe. The patient flexes the neck toward the side being palpated.C This is incorrect to palpate the right lobe. The patient flexes the neck toward the side being palpated, but does not rotate the head.D This is not part of the thyroid palpation.DIF: Cognitive Level: Apply REF: 177TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 61. When palpating the right lobe of the patients thyroid gland using the anterior approach, the nurse feels the tissue between which two structures?a. Sternocleidomastoid and the trapezius musclesb. Trapezius muscle and the tracheac. Cricoid process and the trachead. Sternocleidomastoid muscle and the tracheaANS: D FeedbackA This is not the correct location for palpating the thyroid gland using the anterior approach.B This is not the correct location for palpating the thyroid gland using the anterior approach.C This is not the correct location for palpating the thyroid gland using the anterior approach.D This is the correct location for palpating the thyroid gland using the anterior approach.DIF: Cognitive Level: Apply REF: 177TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 62. On palpation the nurse determines that the patients left thyroid lobe is larger than the right thyroid lobe. What is the nurses most appropriate action at this time?a. Refer the patient to the health care provider for further evaluation.b. Document that the patients thyroid is normal on palpation.c. Palpate the left thyroid lobe again using very firm pressure.d. Ask the patient to flex the chin toward his chest and palpate again.ANS: A FeedbackA The nurse found an abnormality that needs referral for follow-up.B This is not an appropriate action because the nurse found an abnormality.C Repeating the examination will yield the same abnormal finding.D Repeating the examination will yield the same abnormal finding.DIF: Cognitive Level: Analyze REF: 178TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 63. A teenager comes to the clinic complaining about the whiteheads and blackhead on his face interfering with his social life. During the examination the nurse palpates an enlarged submental lymph node. Where is this lymph node located?a. In front of the earb. Under the mandiblec. At the base of the skulld. Along the angle of the jawANS: B FeedbackA This is the location of the preauricular lymph nodes.B This is the location of the submental lymph node.C This is the location of the occipital lymph nodes.D This is the location of the parotid lymph nodes.DIF: Cognitive Level: Apply REF: 178TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 64. How does the nurse test the function of the patients spinal accessory nerve (CN XI)?a. Ask the patient to stick out the tongue and move it side to side.b. Ask the patient to shrug the shoulders against the resistance of the nurses hands.c. Ask the patient to open the mouth and observe the uvula rise when he says ah.d. Ask the patient to move the chin to the chest and then up toward the ceiling.ANS: B FeedbackA This is a test of the hypoglossal cranial nerve (XII).B This is the correct technique for assessing the spinal accessory cranial nerve (XI).C This is a test for cranial nerves IX (glossopharyngeal) and X (vagus).D This technique assesses the range motion of the neck.DIF: Cognitive Level: Apply REF: 176TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 65. A patient complains of sore throat, pain with swallowing, fever, and chills. The nurse suspects tonsillitis and plans to palpate the anterior cervical lymph nodes. Where does the nurse place his fingers to palpate these nodes?a. In front of the earsb. Under the mandiblesc. Along the angle of the mandiblesd. Adjacent to the sternocleidomastoid musclesANS: D FeedbackA This is the location of the preauricular lymph nodes.B This is the location of the submental and submandibular lymph nodes.C This is the location of the parotid lymph nodes.D This is the location of the anterior cervical lymph nodes.DIF: Cognitive Level: Understand REF: 178TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific Assessments 66. What instructions does the nurse give the patient before palpating the right supraclavicular lymph nodes?a. Lean your head backward and toward the right as far as comfortably possible.b. Lie supine and turn your head away from the right side.c. Draw up your shoulders forward, and flex your chin toward the right side.d. Sit up, raise both arms over your head, and flex your chin away from the right side.ANS: C FeedbackA This is incorrect. The patient should draw up (hunch) the shoulders forward rather than leaning back.B The patient should be sitting, rather than lying down.C This is the technique for palpating the supraclavicular nodes.D The shoulders should be drawn up (hunched) forward, rather than raising the arms.DIF: Cognitive Level: Apply REF: 178TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 67. A patient has had an infected facial wound for more than 3 months. How does the nurse expect the patients enlarged lymph nodes to feel?a. Soft, edematous, and tenderb. Round, tender, and movablec. Hard, nontender, and nonmobiled. Irregularly shaped, tender, and firmANS: B FeedbackA These are not characteristics of lymph nodes associated with inflammation.B These are characteristics of enlarged lymph nodes associated with inflammation.C These are characteristics of enlarged lymph nodes associated with a malignancy.D These are not characteristics of lymph nodes associated with inflammation.DIF: Cognitive Level: Analyze REF: 178TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 68. A nurses presentation to patients on risk factors for oral cancer includes which fact?a. The peak incidence oral cancer is before 40 years of age.b. Women have a higher risk than men.c. Excessive alcohol consumption is a risk factor.d. Eating a low fiber diet is a risk factor.ANS: C FeedbackA There is increased incidence after age 40 with peak incidence between ages 64 and 74.B There is a 2:1 men-to-women incidence.C Seventy-five to eighty percent of individuals who develop oral cancer consume excessive amounts of alcohol.D A low fiber diet increases the risk for colon cancer, but not oral cancer.DIF: Cognitive Level: Understand REF: 181TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs 69. During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what does the nurse expect for during the examination of this patients mouth?a. Cracks and erythema in the corners of the mouthb. Slightly rough papillae on the dorsal surface of the tonguec. Smooth or beefy, red-colored, edematous tongued. Painless, nonhealing mouth ulcersANS: D FeedbackA This may be caused by vitamin B deficiencies.B These are an expected finding on the tongue.C This may be an indication of anemia.D This may indicate oral cancer.DIF: Cognitive Level: Apply REF: 181TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 70. A nurses presentation to patients on risk factors for macular degeneration includes which fact?a. The peak incidence is before 60 years of age.b. Women have a higher risk than men.c. Eating a low fat diet causes a vitamin A deficiency, which increases risk.d. Cigarette smokers have twice the risk as nonsmokers.ANS: D FeedbackA Macular degeneration exists in 25% of those between ages 65 and 74 years, and 33% of those older than 75 years.B There are no differences between genders for macular degeneration.C A diet high in monosaturated, polyunsaturated, and vegetable fats increases risk.D Smoking is a risk factor for macular degeneration.DIF: Cognitive Level: Understand REF: 181TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs MULTIPLE RESPONSE 1. During an examination of the head and neck of a healthy adult, the nurse expects which findings? Select all that apply.a. Small red lesions with white flakes scattered on the scalpb. The head and facial bones are proportional for the size of the bodyc. Depressions palpated on the right and left sides over the parietal bonesd. Head held flexed 15 degrees to the lefte. Face and jaw are symmetric and proportionalf. Temporomandibular joint moves smoothlyANS: B, E, FCorrect: These are expected findings from an assessment of the head of a healthy adult.Incorrect: Small red lesions with white flakes scattered on the scalp is an abnormal finding. The scalp should be intact without lesion or flakes. Depressions palpated on the right and left sides over the parietal bones is an abnormal finding. Perhaps this patient had skull tongs from cervical traction at one time. Head held flexed 15 degrees to the left is an abnormal finding. The head should be erect. DIF: Cognitive Level: Analyze REF: 148| 179TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance 2. A nurse is assessing the eyes of a healthy 72-year-old adult. What findings does the nurse expect? Select all that apply.a. Bulbar conjunctiva pink and clear, with small red vessels notedb. Sclera yellow and moist, cornea transparentc. Extraocular movement symmetric with peripheral vision notedd. Newspaper held at 18 inches to see clearlye. Sclera visible between upper lid and irisf. Gray to white circle noted where the sclera merges with the corneag. Light reflects on the cornea at 12 oclock in each eyeANS: A, C, GCorrect: These are expected findings from an assessment of the eyes of a healthy adult.Incorrect: Sclera should be white and moist. Newspaper held at 18 inches to see clearly is due to presbyopia due to the patients age. Patient must hold paper further away to see clearly. The upper lid should cover the upper part of the iris. Sclera is visible in hyperthyroidism. A gray to white circle is arcus senilis, which is an abnormal finding in older adults. DIF: Cognitive Level: Apply REF: 137| 150| 152-153| 179TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 3. During an eye assessment, the nurse asks the patient to keep the head stationary and by moving the eyes only follow the nurses finger as it moves side to side, up and down, and obliquely. This assessment technique collects what data about which cranial nerves? Select all that apply.a. Cranial nerve II (optic)b. Cranial nerve III (oculomotor)c. Cranial nerve IV (trochlear)d. Cranial nerve VI (abducens)e. Cranial nerve V (trigeminal)ANS: B, C, DCorrect: Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) provide muscle movement for the eyes.Incorrect: Cranial nerve II (optic) provides vision. Cranial nerve V (trigeminal) provides movement for the jaw and sensation for cornea, conjunctive, eyelids, teeth, tongue, and mouth. DIF: Cognitive Level: Apply REF: 154-155TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 4. What findings does the nurse expect when assessing the ears of a healthy adult? Select all that apply.a. Cerumen noted in the outer ear canalb. Pinna located below the external corner of the eyec. Cone of light located in the 5 oclock position in the left eard. Ratio of air conduction to bone conduction 2:1e. Tympanic membrane pearly grayf. Whispered words repeated accuratelyANS: A, D, E, FCorrect: These are all expected findings from an assessment of the ears of a healthy adult.Incorrect: The pinna should align with the outer canthus of the eye. Cone of light should be located in the 7 oclock position in the left ear and the 5 oclock position in the right ear. DIF: Cognitive Level: Apply REF: 163-165| 168| 179TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 5. Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply.a. Lips appear pink, smooth, moist, and symmetricb. Teeth are white, yellow, or gray, with smooth edgesc. Exposed tooth neck and brown spots between teethd. Slight roughness on the dorsum of the tonguee. Hard palate appears smooth, pale, and immovablef. Mucous membranes are dry and intactANS: A, B, D, ECorrect: These are all expected findings from a mouth assessment of a healthy adult.Incorrect: Receding gums expose tooth neck and may indicate gingival disease. Brown s

Lungs and Respiratory System

1. A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years?a. 10b. 20c. 40d. 60ANS: C 2. After taking a brief health history, a nurse needs to complete a focused assessment on which patient?a. A male who works as a painterb. A male who plays basketball and hockeyc. A female who recently moved into a college dormitoryd. A female who has a history of goutANS: A 3. During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms?a. Virusb. Allergyc. Fungusd. BacteriaANS: D 4. During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data?a. Does the sputum have an odor?b. Do you have chest pain when you take a deep breath?c. Have you also experienced tightness in your chest?d. Have you coughed up any blood?ANS: A 5. Which question will give the nurse additional information about the nature of a patients dyspnea?a. How often do you see the physician?b. How has this condition affected your day-to-day activities?c. Do you have a cough that occurs with the dyspnea?d. Does your heart rate increase when you are short of breath?ANS: B 6. A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurses examination, what findings will suggest that the cause of this patients dyspnea is due to heart disease rather than respiratory disease?a. Increased anteroposterior diameterb. Clubbing of the fingersc. Bilateral peripheral edemad. Increased tactile fremitusANS: C 7. During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination?a. Increased tactile fremitusb. Inspiratory and expiratory wheezingc. Tracheal deviationd. An increased anteroposterior diameterANS: D 8. A nurse notices a patients chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately?a. Palpate for tracheal deviation.b. Auscultate for bronchovesicular breath sounds in the lung periphery.c. Palpate posterior thoracic muscles for tenderness.d. Auscultate for absence of breath sounds in the lung periphery.ANS: A 9. A nurse inspects a patients hands and notices clubbing of the fingers. The nurse correlates this finding with what condition?a. Pulmonary infectionb. Trauma to the thoraxc. Chronic hypoxemiad. Allergic reactionANS: C 10. A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patients integumentary system, what finding should the nurse correlate to this respiratory disease?a. Dry, flaky skinb. Clubbing of the fingersc. Hypertrophy of the nailsd. Hair loss from the scalpANS: B 11. A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding?a. Make sure the bell of the stethoscope is used, rather than the diaphragm.b. Hold stethoscope firmly to prevent movement when placed over chest hair.c. Ask the patient not to talk while the nurse is listening to the lungs.d. Change the patients position to ensure accurate sounds.ANS: B 12. A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes?a. Dull sounds on percussionb. Soft, muffled rhonchi heard over the tracheac. Bubbling or rasping sounds heard over the trachead. High-pitched sounds on inspiration and exhalationANS: D 13. A nurse auscultates low-pitched, coarse snoring sounds in a patients lungs during inhalation. What is the most appropriate action for the nurse to take at this time?a. Palpate the posterior thorax for vocal fremitus.b. Ask the patient to cough and repeat auscultation.c. Auscultate the posterior thorax for vocal sounds.d. Percuss the posterior thorax for tone.ANS: B 14. A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patients lungs?a. Vesicular breath sounds heard in peripheral lung fieldsb. Bronchial breath sounds heard over the bronchic. Bronchovesicular breath sounds heard over the apicesd. Rhonchi heard over the main bronchiANS: A 15. The nurse is comparing pitch and duration of the various types of a patients breath sounds and recognizes which one of these as an expected finding?a. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory ratio.b. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio.c. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versus-expiratory ratio.d. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio.ANS: B 16. On inspection, a nurse finds the patients anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?a. Increased vocal fremitus on palpationb. Dull tones heard on percussionc. Decreased breath sounds on auscultationd. Complaint of sharp chest pain on inspirationANS: C 17. Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult?a. In the lower lobesb. Over the tracheac. In the apices of the lungsd. Near the sternal borderANS: D 18. A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination?a. Increased fremitus over the left chestb. Tracheal deviation to the left sidec. Hyporesonant percussion tones over the left chestd. Distant to absent breath sounds over the left chestANS: D 19. A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use?a. Place the palmar side of each hand against the lateral thorax at the level of the waist, ask the patient to take a deep breath, and observe lateral movement of the hands.b. Place both thumbs on either side of the patients T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs.c. Place both thumbs on either side of the patients T7 to T8 spinal processes, extend fingers laterally, ask the patient to exhale deeply, and observe lateral inward movement of the thumbs.d. Place the palmar side of each hand on the shoulders of the patient, ask the patient to sit up straight and take a deep breath, and observe symmetric movement of the shoulders.ANS: B 20. A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation?a. Bronchophony reveals the patients spoken 99 as clear and loud.b. No sounds are expected since sounds cannot be transmitted through consolidation.c. Egophony reveals indistinguishable sounds when the patient says e-e-e.d. Whispered pectoriloquy reveals a muffled sound when the patient says 1-2-3.ANS: A 21. A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use?a. Systematically percuss the posterior chest wall following the same pattern that is used for auscultation and listen for a change in tone from resonant to dull.b. Place the pads of the fingers on the right and left thoraces and palpate the texture and consistency of the skin feeling for a crackly sensation under the fingers.c. Place the palms of the hands on the right and left thoraces, ask the patient to say 99, and feel for vibrations.d. Place both thumbs on either side of the patients spinal processes, extend fingers laterally, ask the patient to take a deep breath, and feel for vibrations.ANS: C 22. A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination?a. An increase in the anteroposterior to lateral ratiob. Hyperresonance over the affected areac. Absent breath sounds in the affected aread. Increased vocal fremitus over the affected areaANS: C 23. A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem?a. The nurse documents clearly hearing the patient say 99.b. The nurse documents hearing muffled sounds when the patient says 1-2-3.c. The nurse documents hearing no sounds when the patient says e-e-e.d. The nurse documents clearly hearing the patient say a-a-a.ANS: B 24. In reviewing the patients record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding?a. Asymmetric expansion of the chest wall on inhalationb. Increased transmission of vocal vibrations on auscultationc. Crackling sensation under the skin of the chest on palpationd. Coarse grating sounds heard over the mediastinum on inspirationANS: C 25. Which patient should the nurse assess first?a. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right.b. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever.c. The patient who is short of breath, using pursed-lip breathing, and in a tripod position.d. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and expiratory wheezes.ANS: A 26. A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate on examination?a. Decreased breath sounds on auscultationb. Increased tactile fremitus and dull percussion tonesc. Inspiratory wheezing found on auscultationd. Muffled sounds heard when the patient says e-e-eANS: B 27. A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the significance of this finding?a. An expected findingb. Chronic obstructive pulmonary diseasec. Bilateral pneumoniad. Bilateral pneumothoraxANS: C MULTIPLE RESPONSE 1. What are the functions of the upper airways? Select all that apply.a. Conduct air to lower airway.b. Provide area for gas exchange.c. Prevent foreign matter from entering respiratory system.d. Warm, humidify, and filter air entering lungs.e. Provide transportation of oxygen and carbon dioxide between alveoli and cells.ANS: A, C, DCorrect: These are functions of the upper airway.Incorrect: Gas exchange occurs in the alveoli. The cardiovascular system provides transportation of oxygen and carbon dioxide between alveoli and cells. DIF: Cognitive Level: Remember REF: 193-194TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. On inspection, the nurse finds the patients anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? Select all that apply.a. Inspiratory wheezing found on auscultationb. Hyperresonance heard on percussionc. Decreased breath sounds heard on auscultationd. Deceased diaphragmatic excursion on percussione. A sharp, abrupt pain reported when the patient breathes deeplyf. Decreased to absent vibration on vocal fremitusANS: B, C, D, FCorrect: These are all indications of enlargement or destruction of alveoli that occurs in emphysema. Air is trapped, which increases the anteroposterior to lateral diameter creating a barrel chest, and pushes the diaphragm down decreasing the excursion and causing hyperresonance. The destroyed alveoli decrease the breath sounds and create absent vibration on vocal fremitus.Incorrect: Inspiratory wheezing found on auscultation indicates narrowed airways as found in asthma. A sharp, abrupt pain reported when the patient breathes deeply is pleuritic chest pain associated with pleural lining irritation that may occur in a patient with pleurisy or pneumonia. DIF: Cognitive Level: Analyze REF: 207| 210-213| 215| 219TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 3. On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles. What other findings does this nurse expect during the examination? Select all that apply.a. Dull tones to percussionb. Increased vibration on vocal fremitusc. Feverd. Decreased diaphragmatic excursione. A sharp, abrupt pain reported when patient breathes deeplyf. Muffled sounds heard when the patient says e-e-eANS: A, B, C, ECorrect: These abnormal findings are consistent with consolidation that may occur with pneumonia.Incorrect: Decreased diaphragmatic excursion occurs when the lung is overinflated as in emphysema. Muffled sounds when the patient says e-e-e is an expected finding. With a consolidation, the sound of e-e-e would be clear. DIF: Cognitive Level: Analyze REF: 198-199| 210-211| 215| 218TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 4. A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? Select all that apply.a. Thoracic expansion that is symmetric bilaterallyb. Respiratory rate of 24 breaths/minc. Bronchophony revealing clear voice soundsd. Breath sounds clear with vesicular breath sounds heard over most lung fieldse. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameterf. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spineANS: A, D, E, F

Abdomen

1. A patient tells the nurse, Ive been having pain in my belly for several days that gets worse after eating. Which datum from the symptom analysis is consistent with the nurses suspicion of peptic ulcer disease?a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating.b. Sharp midepigastric pain radiates to the jaw.c. Intermittent cramping pain in the left lower quadrant is relieved by defecation.d. Colicky pain is felt near the umbilicus with vomiting and constipation.ANS: A 2. During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis?a. Have you noticed any swelling in your ankles or feet at the end of the day?b. Have you noticed a change in the color of your urine or stools?c. Have you vomited up any blood in the last 24 hours?d. Have you experienced fever, chills, or sweating?ANS: B 3. A patient reports having frequent heartburn. Which question does the nurse ask in response to this information?a. Has your abdomen been distended when you feel the heartburn?b. What have you eaten in the last 24 hours?c. Is there a history of heart disease in your family?d. How long after eating do you have heartburn?ANS: D 4. A patient reports having abdominal distention. The nurse notices that the patients sclerae are yellow. What question is appropriate for the nurse to ask in response to this information?a. Has there been a change in your usual pattern of urination?b. Have you had any nausea or vomiting?c. Has there been a change in your bowel habits?d. Have you had indigestion or heartburn?ANS: B 5. A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information?a. Has there been a change in your usual pattern of urination?b. Did you have heartburn before the vomiting?c. What did the vomitus look like?d. Have you noticed a change in the color of your urine or stools?ANS: C 6. A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms?a. Do you have the feeling that you cannot wait to urinate?b. Are you urinating a large amount each time you go to the bathroom?c. Has the color of your urine changed lately?d. Have you noticed any swelling in your ankles at the end of the day?ANS: A s 7. In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient?a. Have you had any pain in your abdomen?b. Have you had an unexpected weight gain?c. Have you noticed a change in the color of your skin?d. Have you had any nausea or vomiting?ANS: B 8. A patient reports having abdominal distention. The nurse observes that the patients sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patients abdomen?a. Decreased bowel sounds in all quadrantsb. Glistening or taut skin of the abdomenc. Bulge in the abdomen when coughingd. Bruit around the umbilicusANS: B 9. When inspecting a patients abdomen, which finding does the nurse note as normal?a. Engorgement of veins around the umbilicusb. Sudden bulge at the umbilicus when coughingc. Visible peristalsis in all quadrantsd. Silver-white striae extending from the umbilicusANS: D 10. When inspecting a patients abdomen, the nurse notes which finding as abnormal?a. Protruding abdomen with skin that is lighter in color than the arms and legsb. Marked rhythmic pulsation to the left of the midlinec. Faint, fine vascular networkd. Small shadows created by changes in contourANS: B 11. On inspection of a female patients abdomen, the nurse asks the patient to raise her head without using her arms and notes a midline bulge. What is the appropriate response of the nurse at this time?a. Ask the patient to cough to see if the bulge reappears.b. Auscultate the patients abdomen for hypoactive bowel sounds.c. Document this as a normal finding and continue the examination.d. Perform light and deep palpation of the abdomen.ANS: C 12. A nurse notices abdominal distention when inspecting a patients abdomen. What action does the nurse take next to gain further objective data?a. Place a measuring tape around the superior iliac crests.b. Assist the patient to turn on to the left side and then the right side.c. Ask the patient to cough while lying supine.d. Use the fingertips to sharply strike one side of the abdomen.ANS: A 13. A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next?a. Palpate lightly for tenderness and muscle tone.b. The tip of the middle finger of the dominant hand strikes the nail of the middle finger touching the skin of the abdomen.c. Palpate deeply for masses or aortic pulsation.d. Percuss for tones.ANS: B 14. How does the nurse accurately assess bowel sounds?a. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant.b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.c. Press the bell of the stethoscope firmly against the abdomen in each quadrant.d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.ANS: B 15. When auscultating a patients abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched murmurs over the right and left upper midline. What do these sounds indicate?a. Expected peristalsisb. Femoral artery stenosisc. Renal artery stenosisd. Hyperactive bowel soundsANS: C 16. What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient?a. Bowel soundsb. Venous humc. Soft, low-pitched murmurd. No soundsANS: D 17. What instructions does the nurse give a patient before palpating the abdomen?a. Bend the knees.b. Take a deep breath and hold it.c. Take a deep breath and cough.d. Place the hands over the head.ANS: A 18. A patient reports intermittent cramping abdominal pain that is relieved by having a bowel movement. The patient complains of having the pain at this time, which is why she is seeking care. Which abnormal finding does the nurse anticipate finding on examination of this patients abdomen?a. Decreased bowel soundsb. Bulge in the abdomen when coughingc. Palpable mass in the left lower quadrantd. Bruit around the umbilicusANS: C 19. Using deep palpation of a patients epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurses most appropriate response?a. Auscultate this area using the bell of the stethoscope.b. Percuss the area for tones.c. Ask the patient if there is pain in this area.d. Document this as a normal finding.ANS: D 20. What technique does a nurse use when performing deep palpation of a patients abdomen?a. Places the left hand under the ribs to lift them upb. Asks the patient to breathe slowly through the mouthc. Positions the patient on the right side with knees flexedd. Uses the heel of the hand to depress the abdomenANS: B 21. To correctly percuss the abdomen, a nurse places the distal aspect of the middle finger of the nondominant hand against the skin of the abdomen, and the other fingers are spread apart and slightly lifted off the skin. How does the nurse use the fingers of the dominant hand?a. The pad of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen.b. The tip of the middle finger strikes the nail of the middle finger touching the skin of the abdomen.c. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen.d. The pads of the index and middle fingers strike the nail of the middle finger touching the skin of the abdomen.ANS: C 22. Which sound does a nurse expect to hear when percussing a patients abdomen?a. Tympany over all quadrantsb. Resonance over the upper quadrants and tympany in the lower quadrantsc. Dull sounds over the upper quadrants and hollow sounds over the lower quadrantsd. Dull sounds over the stomach and resonant sounds over the bladderANS: A 23. A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours?a. Absent bowel soundsb. Hyperactive bowel soundsc. Tympanic tones over the lower abdomend. Dull tones over the suprapubic areaANS: D 24. When assessing an adults liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurses appropriate action at this time?a. Document this as an expected finding for this adult.b. Palpate the gallbladder for tenderness.c. Palpate the upper liver border on deep inspiration.d. Use the hooking technique to palpate the lower border of the liver.ANS: C 25. Which location does a nurse select when palpating a patients liver? a. A (right lower quadrant)b. B (right upper quadrant)c. C (left upper quadrant)d. D (left lower quadrant)ANS: B 26. On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes tenderness. This finding may indicate a disorder in which organ?a. Spleenb. Gallbladderc. Sigmoid colond. Left ovaryANS: A 27. The nurse recognizes which clinical finding as expected on palpation of the abdomen?a. Inability to palpate the spleenb. Left kidney rounded at 2 cm below the costal marginc. Slight tenderness of the gallbladder on light palpationd. Bounding pulsation of the aorta over the umbilicusANS: A 28. The nurse observes a patient rocking back and forth on the examination table in pain. Based on the patients history, the nurse suspects kidney stones. What additional examination technique does the nurse perform to confirm this suspicion?a. Palpating the flank area for rebound tendernessb. Percussing the bladder for fullnessc. Percussing the costal vertebral margins for tendernessd. Palpating McBurney point for tendernessANS: C 29. Which techniques does a nurse use to palpate a patients right kidney?a. Asks the patient to take a deep breath, elevates the patients eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right handb. Asks the patient to exhale, elevates the patients eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right handc. Asks the patient to take a deep breath, elevates the patients right flank with the left hand, and deeply palpates for the right kidney with the right handd. Asks the patient to exhale, elevates the patients right flank with the left hand, and deeply palpates for the right kidney with the right handANS: C 30. When assessing the abdomen of a patient who has fluid in the peritoneal cavity, the nurse expects what change to occur when the patient turns from supine to the left side?a. Movement of the tympanic tones from lateral in the supine position to closer to midline when lying on the left sideb. Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left sidec. Change in bowel sounds from hypoactive in the supine position to hyperactive when lying on the left sided. Change in bowel sounds from hyperactive in the supine position to hypoactive when lying on the left sideANS: B 31. The patient reports right lower quadrant (RLQ) pain that is worse with coughing. Based on the patients history, the nurse suspects appendicitis. What additional examination technique does the nurse perform to confirm this suspicion?a. Placing the hand over the lower right thigh and asking the patient to flex the knee while pushing down on the knee to resist it and noting if the patient complains of painb. Palpating deeply a point of the abdomen, located halfway between the umbilicus and the left anterior iliac crestc. Asking the patient to flex the right hip and knee to 90 degrees, then abducting the leg and noting if the patient complains of paind. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of painANS: D 32. When palpating the abdomen to determine a floating mass, a nurse presses on the abdomen at a 90-degree angle with the fingertips. Which finding indicates a mass?a. An increase in abdominal girthb. A complaint from the patient of a dull pain in the flank areac. A freely movable mass will float upward and touch the fingertipsd. Fluid in the abdomen will shift upward and touch the fingertipsANS: C 33. A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the nurses most appropriate response?a. Dont worry about it, esophageal cancers have a low incidence in men.b. You should not be concerned about esophageal cancer at your age.c. You should consider limiting your alcohol intake to two drinks per day.d. Increasing the fiber and protein in your diet can help you lower your risk.ANS: C 34. Which patient has the lowest risk for colon cancer?a. Patient A is 50 years old, is obese, and has type 2 diabetes mellitus.b. Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily.c. Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease.d. Patient D is 45 years old and has diverticulosis.ANS: D 35. Which assessment technique is the nurse performing in the figure below? a. Direct percussionb. Indirect percussionc. Light palpationd. Deep palpationANS: B MULTIPLE RESPONSE 1. A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive of appendicitis? Select all that apply.a. Pain radiating to the right shoulderb. Pain around the umbilicusc. Pain relieved by lying stilld. Right lower quadrant paine. Increased peristalsisANS: B, C, DCorrect: These are all descriptions of pain related to appendicitis.Incorrect: Pain radiating to the right shoulder is associated with gallbladder disease. Increased peristalsis can be associated with gastroenteritis or diarrhea. DIF: Cognitive Level: Understand REF: 278-279TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is increased in patients with alcoholism? Select all that apply.a. Esophageal cancerb. Stomach cancerc. Pancreatic cancerd. Liver cancere. Colon cancerf. Bladder cancerANS: A, B, D, ECorrect: The risk of esophageal, stomach, liver, and colon cancers are increased by heavy intake of alcohol.Incorrect: The risk of pancreatic and bladder cancers are increased with tobacco. However, the risk for esophageal, stomach, liver, and colon cancers are also increased with tobacco use. DIF: Cognitive Level: Understand REF: 285-285TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention OTHER 1. Put in correct order the steps used to palpate the liver.A. Place your right hand parallel to the right costal margin.B. Ask the patient to take a deep breath.C. Place your right hand parallel to the right costal margin.D. Lift up the eleventh and twelfth ribs with the left hand.E. Press your right hand down and under the coastal margin.F. Ask the patient to take some deep breaths ANS:D, C, A, E, B, F

Nutritional Assessment

1. A patient with mild renal disease has been put on a 2200-calorie per day diet plan with the lowest recommended amount of protein. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of protein in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient the least amount of protein he can eat on his prescribed diet?a. 2200 calories 0.15 = 330/9 calories/gram = 36.6 gb. 2200 calories 0.10 = 220/4 calories/gram = 55 gc. 2200 calories 0.20 = 440/9 calories/gram = 48.8 gd. 2200 calories 0.12 = 264/4 calories/gram = 66 gANS: D 2. A patient is put on an 1800-calorie a day diet plan. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of carbohydrates in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient of the maximum grams of carbohydrates she can eat on her prescribed diet?a. 1800 calories 0.45 = 810/4 calories/gram = 202.5 gb. 1800 calories 0.60 = 1080/4 calories/gram = 270 gc. 1800 calories 0.55 = 990/9 calories/gram = 110 gd. 1800 calories 0.50 = 900/9 calories/gram = 100 gANS: B 3. A patient tells the nurse that she tries to keep her fat intake at less than 15% of her total caloric intake per day. What is the nurses most appropriate response to this patients comment?a. That is admirable; how do you accomplish fat intake that low on a daily basis?b. Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat.c. Limiting fat prevents some diseases, but your fat intake is much lower than the 25% recommended.d. If you want to bring your fat intake down further, you might want to eliminate eating fast foods.ANS: C 4. A patient who keeps his fat consumption at 10% of his total caloric intake is at risk for deficiency of which nutrient(s)?a. Ironb. Vitamins A, D, and Kc. Zincd. B and C vitaminsANS: B 5. A nurse is asking questions about the present health status of a young woman who has lost weight recently. Which question is most appropriate when inquiring about present health status?a. What concerns have you had in the past regarding your weight?b. Do you have anorexia?c. Describe the recent changes in your weight.d. Do you have a family history of eating disorders?ANS: C 6. While assessing a patients ability to consume food, the nurse recalls which types of foods are the easiest to chew and swallow?a. Thin liquidsb. Soft foodsc. Dry foodsd. Chewy foodsANS: B 7. Which tool is the best choice for a nurse to use as a quick screening tool to assess a patients dietary intake?a. Food diaryb. Calorie countc. Comprehensive diet historyd. 24-hour recallANS: D 8. A nurse calculates a patients body mass index (BMI) as 33. This measurement indicates which class of weight?a. Overweightb. Obesity class Ic. Obesity class IId. Obesity class IIIANS: B 9. Nurses use which measurement as the most highly correlated with risk of morbidity and mortality?a. Waist-to-hip ratiob. Triceps skinfold measurec. Desirable body weightd. Body mass index (BMI)ANS: D 10. What is the desired body weight for a male who is 7 feet tall?a. 178 lbb. 225 lbc. 250 lbd. 275 lbANS: C 11. During a physical examination, the nurse notes that the patients skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?a. Vitamin Cb. Vitamin Bc. Essential fatty acidd. ProteinANS: C 12. Which patient needs to be taught about how diet and exercise can lower lipids to reduce the risk for coronary artery disease?a. A woman with a high-density lipoprotein (HDL) level of 53 mg/dlb. A man with an HDL level of 43 mg/dlc. A woman with a low-density lipoprotein (LDL) level of 125 mg/dld. A man with an LDL level of 200 mg/dlANS: D 13. Which patient may require additional nutritional assessment?a. A male patient with a blood glucose level of 100 mg/dlb. A pregnant patient with a hemoglobin level of 10.5 g/dlc. A female patient with a prealbumin level of 25 mg/dld. A male patient with a serum triglyceride level of 100 mg/dlANS: B 14. During a physical examination, the nurse notes that the patients skin is dry and flaking, with patches of eczema, and suspects a nutritional deficiency. What additional data should the nurse expect to find to confirm the suspicion?a. Hair loss and hair that is easily removed from the scalpb. Inflammation of the tongue and fissured tonguec. Inflammation of peripheral nerves, and numbness and tingling in extremitiesd. Fissures and inflammation of the mouthANS: A 15. A male patient weighs 205 lb and his desired body weight (DBW) is 190 lb. How should the nurse counsel this patient about his weight?a. He has mild obesity and needs to increase exercise and assess his diet for nutrients and calories.b. He has moderate obesity and needs to consult a health care provider about weight loss therapy.c. He is within normal limits and need not be concerned at this time.d. Further data are needed before an interpretation can be determined.ANS: C 16. A patients current body weight (304 lb) and his desirable body weight of 190 lb. How does the nurse classify this patients weight?a. Within expected rangeb. Mildly obesityc. Moderate obesityd. Morbid obesityANS: C 17. Which patient has the least risk for unhealthy fat distribution?a. The man whose triceps skinfold is at the 25th percentileb. The woman whose triceps skinfold is at the 72nd percentilec. The man whose waist circumference is 46 inches and hip circumference is 40 inchesd. The woman whose waist circumference is 30 inches and hip circumference is 38 inchesANS: D 18. A patient who has anorexia nervosa reports a healthy diet and no protein calorie malnutrition. Which lab value best confirms this patients report?a. Prealbuminb. Serum albuminc. Blood glucosed. Serum cholesterolANS: A MULTIPLE RESPONSE 1. A nurse is assessing an 80-year-old patient who is cared for at home by his 79-year-old wife. Which data indicate this patient has malnutrition? Select all that apply.a. Body mass index (BMI) of 17b. Waist-to-hip ratio of 1.0c. Weight loss of 6% since last months visitd. Prealbumin level of 16 mg/dle. Hematocrit level of 50%f. Hemoglobin level of 20 g/dlANS: A, C, FCorrect: A BMI of 18.5 to 24.9 is the normal range, and this patient is below normal. Severe weight loss is a more than 2% weight change over 1 week. The expected hemoglobin for a man is 14 to 18 g/dl. These values may also indicate dehydration.Incorrect: Waist-to-hip ratio of 1.0 is an expected value for men. The expected level for prealbumin is 15 to 36 mg/dl. This hematocrit level is within normal limits. DIF: Cognitive Level: Analyze REF: 86-87| 90| 93TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration COMPLETION 1. A man who is 6 feet 9 inches tall is told by his provider to lose weight so that he is closer to his desired body weight. He asks the nurse, How can I find out what my desired body weight should be? The nurse responds, Let me show you how to calculate it. Your desired body weight (DBW) should be _____ lb. ANS:2326 feet 9 inches = 81 inches. DBW = 106 lb for the first 60 inches + 6 lb for every other inch, which for this man equals 21 inches (81 60 = 21). 21 6 = 126 +106 = 232 lb. DIF: Cognitive Level: Apply REF: 90TOP: Nursing Process: ImplementationMSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration 2. A woman who is 4 feet 11 inches tall is told by her provider to lose weight so that she is closer to her desired body weight. She asks the nurse, How can I find out what my desired body weight should be? The nurse responds, Let me show you how to calculate it. Your desired body weight (DBW) should be _____ lb. ANS:103.254 feet 11 inches = 59 inches. DBW = 105 lb for the 60 inches + 5 lb for every other inch. However this woman is under 5 feet in height. Thus 105 lb/60 inches = 1.75 lb/inch. 1.75 59 inches = 103.25 lb. DIF: Cognitive Level: Apply REF: 90TOP: Nursing Process: ImplementationMSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration

Heart and Peripheral Vascular System

1. A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurses appropriate response? The 128 represents the pressure in your blood vessels when:a. The ventricles relax and the aortic and pulmonic valves open.b. The ventricles contract and the mitral and tricuspid valves close.c. The ventricles contract and the mitral and tricuspid valves open.d. The ventricles relax and the aortic and pulmonic valves close.ANS: B 2. A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a cause of this heart rate?a. Sinoatrial (SA) node failureb. Atrial bradycardiac. A well-conditioned heart muscled. Left ventricular hypertrophyANS: A 3. While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?a. An extra beat just before the S2 heart sound heard during auscultationb. A raspy machine-like or blowing sound heard during auscultationc. A prominent thrust of the heart against the chest wall felt on palpationd. A visible indentation of pericardial tissue noted during inspectionANS: B 4. A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patients chest pain?a. Stable anginab. Esophageal reflux diseasec. Mitral valve prolapsed. CostochondritisANS: D 5. The patient describes her chest pain as squeezing, crushing, and 12 on a scale of 10. This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms?a. Tachycardia, tachypnea, and hypertensionb. Dyspnea, diaphoresis, and palpitationsc. Hyperventilation, fatigue, anorexia, and emotional straind. Fever, dyspnea, orthopnea, and friction rubANS: B 6. When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound?a. A systolic murmurb. An S3 heart soundc. A friction rubd. An S4 heart soundANS: C 7. Which patients statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina?a. No, I have not done anything to strain chest muscles.b. If I take a deep breath, the pain gets much worse.c. This pain feels like theres an elephant sitting on my chest.d. Whenever this pain happens, it goes right away if I lie down.ANS: B 8. While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination?a. Flat jugular neck veinsb. Red, shiny skin on the legsc. Weak, thready peripheral pulsesd. Edema of the feet and anklesANS: D 9. A nurse is assessing a patients peripheral circulation. Which finding indicates venous insufficiency of this patients legs?a. Paresthesias and weak, thin peripheral pulsesb. Leg pain that can be relieved by walkingc. Edema that is worse at the end of the dayd. Leg pain that increases when the legs are loweredANS: C 10. A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?a. 1+ edema of the feet and ankles bilaterallyb. The circumference of the right leg is larger than the left legc. Patchy petechiae and purpura of the lower extremitiesd. Cool feet with capillary refill of toes greater than 3 secondsANS: D 11. How does a nurse accurately palpate carotid pulses?a. Two fingers of each hand are placed firmly over the right and left temples at the same time.b. One finger is placed gently in the space between the biceps and triceps muscles.c. Two fingers are placed at the thumb side of the forearm at the wrist.d. One finger is placed along the right and then the left medial sternocleidomastoid muscle.ANS: D 12. To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm?a. Rhythm 100 beats/minb. Irregular rhythmc. Rhythm noted at +2d. Bounding rhythmANS: B 13. A nurse expects which finding during a cardiovascular assessment of a healthy adult?a. Visible, consistent pulsations of the jugular veinb. Pink nail beds with a 90-degree angle at the basec. Capillary refill of the toes greater than 5 secondsd. Bruits heard on auscultation of the carotid arteriesANS: A 14. Which pulse may be a challenge for a nurse to palpate?a. Temporalb. Femoralc. Popliteald. Dorsalis pedisANS: C 15. When assessing a patient with aortic valve stenosis, the nurse listens for which sound to detect a thrill?a. Sustained thrust of the heart against the chest wall during systoleb. Visible sinking of the tissues between and around the ribsc. Fine, palpable vibration felt over the precordiumd. Bounding pulse noted bilaterallyANS: C 16. A nurse is having difficulty auscultating a patients heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds?a. Lie in a supine position.b. Cough.c. Hold his or her breath for a few seconds.d. Sit up and lean forward.ANS: C 17. While assessing edema on a male patients lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patients leg. How does the nurse document this finding?a. No edemab. 1+ edemac. 2+ edemad. 3+ edemaANS: B 18. Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter that corresponds to the correct stethoscope placement. a. Ab. Bc. Dd. EANS: D 19. Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?a. Pulmonicb. Tricuspidc. Mitrald. AorticANS: B 20. A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment?a. S4 heart soundb. Clubbing of fingersc. Splitting of the S1 heart soundd. Pericardial friction rubANS: A 21. What does the S2 heart sound represent?a. The beginning of systole.b. The closure of the aortic and pulmonic valves.c. The closure of the tricuspid and mitral valuesd. A split heard sound on exhalationANS: B 22. How is the first heart sound (S1) created?a. Pulmonic and tricuspid valves close.b. Mitral and aortic valves close.c. Aortic and pulmonic valves close.d. Mitral and tricuspid valves close.ANS: D 23. A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve?a. Second intercostal space, right sternal borderb. Second intercostal space, left sternal borderc. Fourth intercostal space, left sternal borderd. Fifth intercostal space, left midclavicular lineANS: A 24. A nurse who is auscultating a patients heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding?a. An opening snapb. A diastolic murmurc. A systolic murmurd. A pericardial friction rubANS: C 25. A nurse determines that a patients jugular venous pressure is 3.5 inches. What additional data does the nurse expect to find?a. Weight lossb. Tented skin turgorc. Peripheral edemad. Capillary refill greater than 5 secondsANS: C 26. How does a nurse assess the competence of venous valves in patients who have varicose veins?a. Notes how quickly veins fill after lifting one leg above the level of the heartb. Assesses for Homan sign in both lower extremities while the patient is supinec. Assesses capillary refill on the toes of both feet while the patient is sitting in the chaird. Measures the circumference of both calves and compares the resultsANS: A 27. Which patient does the nurse identify as the one at greatest risk for hypertension?a. Woman with coronary artery diseaseb. Hispanic malec. Obese male with diabetes mellitusd. Postmenopausal womanANS: C 28. After two separate office visits, the nurse suspects that a patient is developing Stage 1 hypertension based on which consecutive blood pressure readings?a. Visit 1, 118/78; Visit 2, 116/76b. Visit 1, 130/88; Visit 2, 134/88c. Visit 1, 144/92; Visit 2, 150/90d. Visit 1, 162/100; Visit 2, 166/104ANS: C 1. During a health fair, the nurse is alert for which risk factors for hypertension? Select all that apply.a. Excessive protein intakeb. Having parents with hypertensionc. Excessive alcohol intaked. Being Asiane. Experiencing persistent stressf. Elevated serum lipidsANS: B, C, E, FCorrect: These are all risk factors for hypertension.Incorrect: Excessive protein is not a risk factor for hypertension, but excessive sodium intake is a risk factor. Being Asian is not a risk factor, but being African-American is a risk factor. DIF: Cognitive Level: Analyze REF: 261TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems 2. A patient with heart failure reports having a cough with frothy sputum and awakening during the night to urinate. Based on this information, what abnormal data might this nurse expect to find during an examination? Select all that apply.a. S4 heart soundb. Dyspneac. Jugular vein distentiond. Pericardial friction rube. Edema of ankle and feet at the end of the dayf. S3 heart soundANS: B, C, E, FCorrect: All of these manifestations are consistent with fluid overload that occurs in heart failure because the cardiac output is decreased.Incorrect: S4 heart sounds signifies a noncompliant or stiff ventricle. Hypertrophy of the ventricle precedes a noncompliant ventricle. Also, coronary artery disease is a major cause of a stiff ventricle. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac. DIF: Cognitive Level: Analyze REF: 230| 233| 238| 247| 252-253| 260TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 3. What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply.a. Heart rate of 102 beats/minb. S1 and S2 present with regular rhythmc. Capillary refill greater than 3 secondsd. Blood pressure of 124/86e. Warm, elastic turgorf. Pulse of smooth contour with 2+ amplitudeANS: B, E, F

Reproductive System and the Perineum

1. During the initial inspection of the female genitalia, the nurse recognizes which finding as normal?a. The labia minora are hair-covered and lying within the labia majora.b. The cervical os in the multiparous woman has the shape of a small circle.c. The vaginal vestibule lies between the labia minora and contains the urinary meatus.d. The openings of Skene and Bartholin glands are visible posteriorly.ANS: C 2. The pregnant patient tells the nurse that she has had three pregnancies and two live births to date. How does the nurse record this in the patients history?a. Gravida 3, para 3b. Gravida 3, para 2c. Gravida 2, para 3d. Gravida 2, para 2ANS: B 3. A mother asks a nurse when her daughter should get immunized again for human papilloma virus (HPV). What is the nurses most appropriate response to this question?a. Your daughter does not need this immunization until she becomes sexually active.b. The recommended age for this immunization is between ages 25 and 30 years of age.c. Between the ages of 11 and 26 years is the recommended time for this immunization.d. When she begins having menstrual periods is the best time for this immunization.ANS: C 4. A patient asks when she should make an appointment for her first Pap (Papanicolaou) test to screen for cervical cancer. What is the nurses most appropriate response?a. There is no need for Pap tests until after you have become pregnant.b. All women should have the first Pap test after reaching menarche.c. All women should have the first Pap test after they are 19 years of age.d. All women should have the first Pap test when they become sexually active or at age 21.ANS: D 5. A patient asks when she can stop having Pap (Papanicolaou) tests. What is the nurses most appropriate response?a. Until you are no longer sexually active.b. Through age 65.c. Until you begin menopause.d. Through the end of menopause.ANS: B 6. When performing a well woman examination, the nurse expects what findings?a. The inner surface of the vestibule is deep pink and moist with a smooth texture.b. The inguinal skin appears wrinkled and moist with sparse hair distribution.c. The labia minora is deeply pigmented, and the tissue is ragged and asymmetrical.d. Pubic hair is distributed evenly over the mons and shaped as a triangle with the apex over the mons.ANS: A 7. The nurse documents which finding as expected on inspection of the anus?a. Skin tone darker and coarser than that of the surrounding skinb. Sphincter lightly closed when the patient is relaxedc. Large amount of stiff, curling hair surrounding the anusd. Slight protrusion under the skin when the patient strains or bears downANS: A 8. On inspection of the internal structure of the vagina, the nurse notes a rounded protrusion on the posterior wall of the vagina. How does the nurse document this finding?a. Rectoceleb. Cystocelec. Bartholin cystd. Nabothian cystANS: A 9. During the examination of the internal genitalia with the speculum, the nurse records which finding as normal?a. A healed laceration of the cervix in a nulliparous patientb. A large amount of thick white drainage from the cervical osc. Deviation of the cervix toward the posterior vaginal walld. Pink cervix with a small ring of reddened tissue near the osANS: D 10. The nurse recognizes that a Papanicolaou (Pap) test is indicated for which patient?a. A 12-year-old who has not yet reached menarche.b. A 30-year-old who had a normal Pap test 12 months ago.c. A 45-year-old who had a total hysterectomy for cervical cancer.d. A 55-year-old who had a total hysterectomy to treat endometriosis.ANS: C 11. What technique does the nurse use to obtain a cervical tissue sample for a Papanicolaou (Pap) test?a. A Cervex-Brush is inserted into the cervix and rotated to obtain a sample of ectocervical and endocervical cells.b. A wooden spatula scrapes the cervix to obtain a sample of endocervical cells.c. A pipette is placed inside the cervical os and rotated to obtain a thick layer of endocervical and ectocervical cells.d. A cotton-tipped applicator is used on the outside of the cervix to obtain ectocervical cells.ANS: A 12. A nurse expects which normal findings when performing a bimanual palpation of the cervix and uterus?a. The uterus feels firm and slightly nodular.b. The cervix feels soft, smooth, and slightly rounded.c. The uterus of a nonpregnant patient cannot be felt with the internal fingers.d. The cervix is tender when moved laterally.ANS: B 13. A nurse expects which normal findings when palpating a patients ovaries?a. Nodular and nonmovableb. Smooth, fluid-filled, and nonmovablec. Smooth, firm, and about the size of a walnutd. Spongy, mobile, and about the size of a peanutANS: C 14. After a rectal examination of a patient with obstructive jaundice, the nurse expects the stool to be what color?a. Tanb. Pale yellowc. Blackd. Bright redANS: A 15. On inspection of the external male genitalia, the nurse notes which finding as abnormal?a. The scrotum is covered with dark rugous skin.b. The skin covering the penis is hairless and loose.c. The urinary meatus is located on the upper surface of the penis.d. The left side of the scrotum hangs slightly lower than the right.ANS: C 16. The nurse observes that the urinary meatus is located on the under surface of the penis. How does the nurse document this finding?a. Balanitisb. Phimosisc. Epispadiasd. HypospadiasANS: D 17. In inspecting the scrotum, the nurse documents which finding as normal?a. The epididymides are round, solid nodular masses.b. The scrotum is deeply pigmented with a rugous surface.c. The scrotal skin is a lighter color than the body skin.d. The vas deferens is palpable bilaterally.ANS: B 18. Which assessment technique does a nurse use to assess the inguinal region and femoral area of a male patient as he is standing and straining?a. Palpates the femoral arteryb. Palpates the inguinal lymph nodesc. Observes for a bulge through the inguinal regiond. Observes for discoloration of the inguinal ringANS: C 19. When palpating the epididymis, the nurse considers which finding to be abnormal?a. The epididymis is located on the posterolateral surface of each testis.b. The epididymis feels like a tubular, comma-shaped structure.c. The epididymis collapses on palpation.d. The epididymis has an irregular, nodular surface.ANS: D 20. When does a nurse use transillumination of the scrotum?a. When the patient has tortuosity of the veins along the spermatic cordb. When the patient has an indirect herniac. When there is a mass or fluid in the epididymisd. When there is twisting of the testicle and spermatic cordANS: C 21. What procedure does a nurse use to assess the inguinal ring of a male patient for a hernia?a. Asks the patient to lie supine, lifts the scrotum, asks the patient to take a deep breath, and observes for a bulgeb. Asks the patient to lean over the examination table, inserts a gloved finger into the lower part of the scrotum into the inguinal canal, asks the patient to cough, and palpates for a bulgec. Asks the patient to lie on the side not being assessed, inserts a gloved finger into the lower part of the scrotum into the inguinal canal, asks the patient to exhale completely, and palpates for a bulged. Asks the patient to stand, inserts a gloved finger into the lower part of the scrotum into the inguinal canal, asks the patient to cough, and palpates for a bulgeANS: D 22. The nurse places a male patient in which position for rectal examination?a. Lithotomy positionb. Prone with the knees fully extendedc. Bending over the table, with feet evertedd. Left lateral position with knees and hips flexedANS: D 23. During an internal examination of a patients anus, the nurse notes that the patient has a hypertonic sphincter. What is the most relevant action for the nurse to take at this time?a. Ask the patient about anxiety or pain related to the examination.b. Inquire if the patient has had any neurologic injury that causes a hypertonic sphincter.c. Refer the patient to the physician for evaluation.d. Question the patient about a history of anal trauma.ANS: A 24. What normal finding does a nurse expect to find when palpating a male patients prostate gland?a. Is approximately 4.5 cm in diameter and is highly mobileb. Feels smooth, firm, and slightly mobilec. Is deeply divided into three lobes, each approximately 2 cm in lengthd. Feels hard, asymmetrical, and has a palpable ridge that divides the gland into two lobesANS: B 25. A 50-year-old patient asks the nurse about her risk of developing a cancer of the reproductive system. What is the appropriate response by the nurse?a. Human papilloma virus infection and cigarette smoking are major risk factors for cervical cancer.b. Some of the risk factors for endometrial cancer include being age 40 or older and having a history of infertility.c. Ovarian cancer is not often seen in women under age 50 or those who have a family history of breast cancer.d. Women who have had menstrual irregularities for many years are at lower risk of developing any of the reproductive system cancers.ANS: A 26. The nurse recognizes which patient has the highest risk of endometrial cancer?a. A 24-year old woman with menarche at age 9b. A 30-year old woman who started menstruating at age 19c. A 42-year old woman who reached menopause at age 40d. A 64-year old woman who had irregular, heavy menstrual cyclesANS: A 27. Which patient does the nurse recognize as having the highest risk for ovarian cancer?a. A 24-year-old nulliparous woman who has a history of multiple sexual partnersb. A 32-year-old woman who has had six live births and a history of human papilloma virus (HPV) infectionc. A 55-year-old woman who reached menarche at age 12 and menopause at age 54d. A 64-year-old nulliparous woman who has taken hormone replacement therapy for eight yearsANS: D 28. The nurse correlates which factor to an increased risk of endometrial cancer in women with early menarche or late menopause?a. Total number of ovulatory cyclesb. Less hormone stimulationc. Need for estrogen replacement in these patientsd. Extended duration of the menstrual cycle in these patientsANS: A 29. A patient complains of dysuria, yellow-green vaginal discharge, and vulvar itching. The nurse suspects which sexually transmitted disease?a. Syphilisb. Gonorrheac. Genital wartsd. ChlamydiaANS: B 30. In assessing a patient with suspected Chlamydia, the nurses actions are guided by which characteristic of this disease?a. Chlamydia is frequently asymptomatic and requires screening.b. Chlamydia is associated with a yellow-green vaginal discharge.c. Chlamydia is accompanied by heavy bleeding and headache.d. Chlamydia is only seen in immunocompromised patients.ANS: A 31. A nurse examines a patient and finds a single, firm, painless open sore with indurated borders on the vulva. The nurse correlates this finding with which disorder?a. Human papillomavirus (HPV) infectionb. Herpes infectionc. Gonorrhead. SyphilisANS: D 32. A nurse expects to find which manifestations in the male patient who has both Chlamydia and gonorrhea?a. Painful urination and purulent urethral dischargeb. A single, firm painless open sore on the shaft of the penisc. Red superficial vesicles on the shaft of the penisd. A single or a cluster of wartlike growth in the anal-rectal areaANS: A 33. While giving a history, the patient reports having herpes genitalis. Based on this information, which finding does the nurse anticipate during the assessment?a. Small vesicles on the genitaliab. Single, firm, painless, open sorec. Pain when palpating the cervixd. Malodorous greenish-yellow vaginal dischargeANS: A 34. In teaching a class of adolescents about sexually transmitted diseases, a nurse includes which information about the human papillomavirus (HPV)?a. HPV is fragile and not easily transmitted.b. Wartlike growths in the genital area are a sign of HPV infection.c. There is a specific blood test needed to screen for HPV.d. Heavy, purulent vaginal discharge is the primary sign of HPV.ANS: B 35. The patient is unable to tolerate a bimanual pelvic examination due to pain in ovaries and fallopian tubes. Which disorder does the nurse suspect?a. Tertiary syphilisb. Genital herpesc. Human papillomavirus (HPV) infectiond. Pelvic inflammatory diseaseANS: D 36. A patient with testicular torsion is experiencing which abnormality?a. Abnormal dilation and tortuosity of the veins along the spermatic cordb. Twisting of the testicle and spermatic cordc. A cystic mass filled with sperm and seminal fluid in the epididymisd. An accumulation of fluid in the scrotumANS: B 37. How does a nurse recognize when a patient has a testicular torsion?a. The nurse sees a light red glow on transillumination of the scrotum.b. The nurse palpates testicular edema that is painless.c. The patient reports a pulling sensation and dull ache of the scrotum.d. The patient complains of sudden onset of severe pain with edema of the scrotum.ANS: D 38. In educating a male patient about testicular cancer, the nurse includes which statement?a. The highest incidence of this cancer is in men between 20 and 34 years of age.b. The incidence of this cancer is correlated with human papillomavirus (HPV) infection.c. The risk of this cancer increases with multiple sexual partners.d. This type of cancer more commonly affects uncircumcised males.ANS: A 39. While taking a history of a patient with an enlarged prostate, the nurse expects the patient to report which symptom?a. Painful urination with each voidingb. Blood in the urine upon arisingc. Waking from sleep to urinated. Incontinence throughout the dayANS: C 40. The nurse correlates which patient complaint with suspected enlargement of the prostate gland?a. Constipationb. Change in bowel patternsc. Weak urine streamd. Increased mucus in urineANS: C 41. While giving a history, a patient reports having a weak urinary stream and feeling that his bladder is not empty after urination. Based on these data, what finding does the nurse anticipate upon examination?a. An enlarged prostate gland palpated on the anterior wall of the rectumb. An indirect hernia palpated through the inguinal ring when the patient coughsc. The foreskin of the penis cannot be returned to position after retraction behind the glansd. A nodular prostate gland palpated on the posterior wall of the rectumANS: A 42. A patient tells the nurse that he has been informed he has internal hemorrhoids and asks whether there are different types of hemorrhoids. What is the nurses most appropriate response?a. Internal hemorrhoids are usually seen outside the anus and appear blue.b. Sometimes patients have other diseases, such as anal warts, that may be mistaken for internal hemorrhoids.c. Internal hemorrhoids are found higher in the rectum and usually cant be felt unless they are infected or prolapsed.d. Both internal and external hemorrhoids arise from the same general area and produce the same kinds of symptoms.ANS: C 43. During a history, a patient reports rectal bleeding, a warning sign of colorectal cancer. The nurse correlates which clinical finding with colorectal cancer?a. Thick, blood-tinged mucus within the rectumb. A pus-filled cavity in the anorectal areac. An irregular mass with raised edges on the rectal walld. A small, smooth nodule protruding from the rectumANS: C MULTIPLE RESPONSE 1. Which comments by a male patient during a health history suggest erectile dysfunction? Select all that apply.a. I have had type 1 diabetes mellitus since I was 8 years old.b. I frequently have urinary tract infections.c. I am taking medications to control my blood pressure.d. I have an enlarged prostate gland.e. I take a diuretic every morning.ANS: A, C, ECorrect: A chronic complication of diabetes can cause impotence. An adverse reaction of some types of antihypertensive and diuretic medications can cause impotence.Incorrect: Urinary tract infections are unrelated to impotence. Having an enlarged prostate causes problems with urinating, but not with erections. DIF: Cognitive Level: Analyze REF: 396TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. Which patients meet the criteria for Chlamydia screening? Select all that apply.a. A 40-year-old woman who is sexually active and uses barrier protection consistentlyb. A 15-year-old female woman who is sexually active with one partnerc. A 22-year-old woman who is sexually active and uses barrier protection inconsistentlyd. A 23-year-old woman who has had four sexual partners in the last 3 monthse. A 34 year-old woman who uses barrier protection inconsistently with multiple sexual partnersf. A 36-year-old pregnant woman making the first prenatal visitANS: B, C, D, E, FCorrect: These patients meet the criteria for screening for Chlamydia.Incorrect: This patient does not meet criteria based on age and use of protection. DIF: Cognitive Level: Analyze REF: 398TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs 3. Which questions are appropriate for a symptom analysis of a patient with benign prostatic hyperplasia? Select all that apply.a. How often have you found that you stopped and started again several times when you urinated?b. How often have you had to urinate again less than 2 hours after you finished urinating?c. How often have you been incontinent of urine?d. How often have you had constipation due to the enlarged prostate?e. How often have you had to push or strain to begin urination?f. How often have you had to get up during the night to urinate?ANS: A, B, E, FCorrect: These questions from the American Urological Association Symptom Index for Benign Prostatic Hyperplasia are used to screen men for an enlarged prostate.Incorrect: The urinary problem is difficulty in starting the urinary stream due to the prostate gland compressing the urethra, thus incontinence is not a manifestation of an enlarged prostate. Although the enlarged prostate is palpated through the rectum, it does not become large enough to cause constipation. DIF: Cognitive Level: Apply REF: 396-397TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 4. Which patients have risk factors for endometrial cancer? Select all that apply.a. The patient who never had children.b. The patient who has given birth to nine children.c. The patient whose body mass index is 39.d. The patient whose menopause began at age 60.e. The patient whose father had colon cancer.f. The patient who has had human papillomavirus (HPV) infections.ANS: A, C, D, E

Breasts and Axillae

1. In teaching a patient about breast self-examination, why does the nurse emphasize palpation of the axillary areas?a. Because deep muscles in that area can mask changesb. Because some patients avoid this area because of tendernessc. Because most lymph draining from the breast flows through this aread. Because supporting ligaments in this area may present as tissue changesANS: C 2. In reviewing the charts of several patients in the clinic, a nurse recognizes which patient as being at highest risk of breast cancer?a. A woman who had her first child at age 26b. A woman who reached menopause at age 58c. A woman who breastfed all four of her childrend. A woman who states that she reached menarche at age 14ANS: B F 3. While giving a presentation about breast health, a nurse informs patients about which recommendation?a. Women in their 30s should have annual clinical breast examinations.b. Women at high risk of breast cancer should have semiannual mammograms.c. Women who are postmenopausal require clinical breast examination every 5 years.d. A screening mammogram is recommended for all women beginning at age 50 years.ANS: D 4. Based on the history, a nurse determines that the patient with which finding requires further assessment?a. Occasional discharge from nipplesb. Supernumerary nipples along the milk linec. Rash in the axillae associated with change in deodorantd. Mild breast swelling that fluctuates with the menstrual cycleANS: A 5. During a breast examination of a healthy female, the nurse recognizes which finding as normal?a. Asymmetrical venous patternb. Unequal nipple sizec. Supernumerary nipples along the milk lined. Pink discharge from one nipple when manipulatedANS: C 6. A patient comes to the clinic complaining of a new onset of nipple discharge. After inspection of the breast and discharge, what action of the nurse has the highest priority?a. Palpating both breasts comparing amount of dischargeb. Asking the patient about breast painc. Asking the patient to raise her arms and comparing the movement of the breastsd. Obtaining a specimen of the discharge for cytologyANS: D 7. What is the purpose of asking a female to lean forward during the breast examination?a. To accentuate the Montgomery glandsb. To observe for symmetry of the suspensory ligamentsc. To compare nipple symmetryd. To identify any breast masses in the subcutaneous tissuesANS: B 8. Which technique does a nurse use to palpate the patients axillary lymph nodes?a. With the patient sitting, the nurse places fingers of both hands deep into the axilla, one hand on either side, and firmly pushes the axillary tissue toward the center to feel for enlarged nodes.b. With the patient lying supine with arms at the sides, the nurse uses the tips of the fingers of one hand to palpate the axilla moving from the posterior to the anterior aspect of the axilla to feel for enlarged nodes.c. With the patient lying supine with the hand behind the head of the side being assessed, the nurse uses the pads of fingers of one hand to systematically palpate the axilla using small circular motions to feel for enlarged nodes.d. With the patient sitting, the nurse places fingers of one hand deep into the axilla and firmly slides the fingers along the patients middle, anterior, and posterior of the axilla to feel for enlarged nodes.ANS: D 9. When examining the lymph nodes of an adult female patient, the nurse recognizes which finding as normal?a. Visible superficial nodesb. Palpable supraclavicular nodesc. Nonpalpable lymph nodes in the axillad. Enlarged, fixed nodes in the neckANS: C 10. A nurse performing a breast examination on a female patient places the patient in a supine position, places a pillow under the right shoulder, and asks the patient to place her right lower arm above her head. What is the reason for this position?a. Flatten the breast tissue evenly over the chest wall.b. Help the patient to relax and feel more comfortable.c. Reveal lumps deep in the breast more easily.d. Expose any drainage from the nipples.ANS: A 11. What instructions does the nurse give a female patient when she is learning to perform breast self-examination?a. Press the pads of the fingers firmly to compress breast tissue against the rib cage.b. Lie in front of a mirror and observe for dimpling of the skin.c. Lift the fingers from the chest wall during palpation to better define the breast tissue.d. Apply gentle pressure while moving the fingers in a pattern across the breast.ANS: D 12. In assessing the breast of a male patient, the nurse places him in which position?a. Standing with hands over the headb. Supine with the hand on the side being examined placed behind the headc. Sitting with arms at the sided. Bending forward 45 degrees at the waistANS: C 13. During a breast examination of a male patient, the nurse recognizes which finding as normal?a. Bilateral nontender flat breasts with symmetric nipple and areolar areasb. A fibrous layer of subcutaneous breast tissue that is thicker than in womenc. Breast tenderness on the dominant side but not on the other sided. Bilateral symmetry of breasts with absence of hair in the areolar areasANS: A 14. Which statement by a 40-year old man would be most indicative of possible breast cancer?a. I had embarrassing breast enlargement when I was a teenager.b. I think I felt a hard spot in my left breast, but it does not hurt.c. My right breast has always been a little smaller than the left.d. My fathers breasts got larger after he was older.ANS: B 15. What technique does a nurse use when performing a breast examination on a patient who has had a mastectomy?a. Excludes palpation of the axillary area where there was lymph node dissectionb. Inspects and palpates both the operative and the nonoperative sidesc. Avoids palpating the scar to prevent causing the patient any discomfortd. Palpates only the muscle tissue on the affected sideANS: B 16. In a presentation on breast cancer risk factors, a nurse would be accurate in making which statement?a. Women who breastfeed their children are at increased risk of breast cancer.b. Women who are more than 30% overweight are at increased risk of breast cancer.c. African American women have the highest risk of breast cancer.d. Women who have children before age 30 are at increased risk of breast cancer.ANS: B 17. A patient comes to the clinic because she found a mass in her left breast that is present during and after her menstrual periods. On palpation the nurse finds a mass in the left breast that is round, rubbery, mobile, and nontender. This finding is consistent with which breast disorder?a. Fibrocystic breast diseaseb. Invasive breast cancerc. Mastitisd. FibroadenomaANS: D 18. A patient had a left radical mastectomy last year. The nurse assesses for painless and nonpitting swelling of the arm on that side. Which complication of a mastectomy is the nurse assessing for?a. Infectionb. Lymphedemac. Inflammationd. LymphomaANS: B 19. In assessing a patient with lymphedema after a mastectomy, the nurse expects which finding?a. Fragile, thin, pale skin covering the area of lymphedemab. Several brownish-red discolorations in the center of the affected armc. Unilateral nonpitting edema of the affected armd. Pitting edema of affected armANS: C 20. A nurse is performing a breast examination of a patient who complains of pain in both breasts that occurs around the time of her menstrual period. The nurse expects which findings during the breast examination?a. Masses in the breasts that are round, soft, mobile, and well-delineatedb. Masses in the breasts that are round, firm, mobile, and well-delineatedc. Masses in the breasts that are irregular, hard, and fixedd. Breast tissue that is red, edematous, tender, and warm to the touchANS: A 21. The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a female patient. What is the most appropriate action for the nurse to take next?a. Record this as an expected finding.b. Palpate the area of dimpling for pain.c. Palpate the borders of the area of dimpling for irregularity.d. Tell the patient that dimpling indicates the mass is benign.ANS: C 22. A nurse becomes suspicious that a patient may have breast cancer based on which abnormal finding?a. An irregularly shaped hard mass in one breastb. Bilateral, small, nontender nodes close to the surfacec. Multiple rubbery-feeling lumps with well-defined bordersd. A mobile, firm lump located in the upper outer quadrant of the left breastANS: A 23. The nurse would give immediate attention to the patient who presents with which complaint?a. Bilateral breast swellingb. Unilateral nipple dischargec. A breast lump that changes during the menstrual cycled. Unequal breast sizeANS: B MULTIPLE RESPONSE 1. Which life style behaviors do nurses ask about to identify patients with risk factors for breast cancer? Select all that apply.a. Obesity after age 50b. Smoking more than one pack of cigarettes a dayc. Never having given birth to a viable infantd. Drinking two to five alcoholic beverages a daye. Estrogen replacement therapy for more than 5 yearsf. High blood pressure for more than 3 yearsANS: A, C, D, E

Culture

1. What are the characteristics of ones culture?a. Color of skin and hairb. System of beliefs and practicesc. Food preferencesd. Language and religionANS: B 2. Which example below best characterizes a patients race?a. The language spoken in the patients home is Tagalog.b. The patients family follows a kosher diet.c. The patient and his family have blonde hair and fair skin.d. The patients grandparents came to the United States from Germany.ANS: C 3. After the death of a Native American man, the nurse opened a window to allow spirits to leave. This action is an example of which attribute of the concept of cultural competence?a. Adapting interventions based on cultural practices (Tailoring)b. Gaining information about cultural differences (Knowledge)c. Considering the effects of anothers values and experiences (Understanding)d. Showing appreciation for cultural differences (Respect)ANS: A 4. A Hispanic patient tells an African American nurse, You are African American and cant possibly understand how a person like me feels. What is an appropriate response by the nurse at this time?a. Find a nurse who is not African American to interview the patient.b. Ask the patient, Why do you think that, since we just met?c. Note that the patient is very defensive about being racially different.d. Encourage the patient to describe what he means by his statement.ANS: D 5. A male nurse is assigned to the care of a gay male with alcoholism. This sexual orientation is inconsistent with the beliefs of the nurse. What actions, if any, can the nurse take to provide patient-centered care to this patient?a. No action is necessary at this time.b. Examine his own feelings about alcoholism and homosexuality.c. Determine the patients degree of risk for contracting the human immunodeficiency virus.d. Discuss homosexuality and alcoholism with the patient.ANS: B 6. Which nursing behaviors indicate culturally competent care?a. Recognizing that there are different definitions of health and illnessb. Complying with the stated plan of treatment despite the patients differing opinionc. Understanding that there is diversity even among people of the same cultural groupd. Helping patients of different cultures adopt the beliefs and behaviors of the dominant cultureANS: C 7. A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of persistent headaches. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time?a. I advise you to stop taking those medicines from the tribal healer.b. Perhaps you should increase the frequency of the healers medicines.c. Tell me about these medicines and how often you are using them.d. Could your headaches be caused by the healers medicines?ANS: C 8. Which question is the most appropriate to learn about a patients religious practices?a. How often do you go to church?b. Where is your church located?c. Do you mind telling me about your religion?d. Do you have any specific religious or spiritual practices or beliefs?ANS: D 9. A patient tells the nurse that her religion prohibits her from eating food prepared outside of a special kitchen. What is the nurses appropriate action to meet this patients needs?a. Call the dietary department to cancel the patients meal tray.b. Tell the patient that her diet must be carefully monitored and prepared at the hospital.c. Tell the patient that because of her illness, a few changes to her religious requirements will be necessary.d. Ask the patient to describe the requirements for the special kitchen.ANS: D 10. Which question is most effective in assessing a patients personal beliefs about health and illness?a. What or who do you believe controls your health?b. Do you see your health care provider annually?c. Do you have specific beliefs about health and illness?d. Who makes the health decisions in your family?ANS: A 11. An Asian woman comes to the clinic with a complaint of back pain. During the history, she tells the nurse that she usually uses acupuncture for her pain. What is the nurses best response?a. When have you used acupuncture, and what effects did it have?b. Acupuncture is good for some problems, but for major illnesses its best to use medications.c. Why did you use acupuncture?d. I have heard that many Asian people use acupuncture.ANS: A 12. A nurse is caring for a woman who has given birth to a healthy baby. The womans husband and mother are in the room, and more family members are in the lobby. Which comment by the nurse demonstrates culturally competent care?a. We need to take your baby to the nursery now for a physical examination.b. Are there any ceremonies or other practices that are important to you at this time?c. We can only allow immediate family in the room with you at this time.d. Because breastfeeding is the best way to feed your baby, well bring your baby to you when she is hungry.ANS: B 13. A nurse can improve cultural awareness with which behavior?a. Being sensitive to differences between the cultures of the nurse and patientb. Making generalizations about various ethnic and cultural groupsc. Learning everything about the various cultural groups in the nurses cityd. Taking a foreign language classANS: A MULTIPLE RESPONSE 1. Which of the components described below represent the Filipino culture? Select all that apply.a. Tagalog and Cebuano are the primary dialects spoken.b. Orientation to the past is evident in their respect for elders.c. The family, rather than the individual, is the unit.d. Most Filipinos are Catholic.e. Filipinos like to eat rice with most meals.f. Sharing is common since interdependence is important.ANS: B, C, FCorrect: Respect for elders is an example of values and beliefs, a part of culture. Value of family represents beliefs and customs of culture. Interdependence is a value of Filipinos.Incorrect: Language, religion, and food preferences are part of ethnicity, rather than culture. DIF: Cognitive Level: Apply REF: 47TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Cultural Diversity 2. During the first prenatal visit for a 20-year-old Hispanic woman, the nurse assesses the patients health beliefs and practices. Which questions are appropriate as part of this assessment? Select all that apply.a. You are Hispanic, do you need me to find an interpreter?b. What is the language that is usually spoken in your home?c. How do you define health and illness?d. Which Catholic church do you attend?e. Do you have specific beliefs or preferences concerning food or food preparation?f. Do you or the members of your family have certain beliefs and practices surrounding pregnancy and childbirth?ANS: B, C, E, F

Mental Health

1. What function do neurotransmitters have in mental health disorders?a. Dopamine levels are increased in schizophrenia.b. Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.c. Serotonin is decreased in a state of anxiety.d. Norepinephrine is increased in depression.ANS: A FeedbackA Dopamine levels are increased in schizophrenia.B Insufficient GABA may contribute to anxiety. GABA is an inhibitory neurotransmitter.C Serotonin is increased in anxiety states.D Norepinephrine is decreased in depression.DIF: Cognitive Level: Remember REF: 66TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts 2. A male patient scores 125 on the Holmes Social Readjustment Scale. How does the nurse interpret this score?a. He is experiencing a great deal of stress in his life and needs hospitalization.b. At this time he has no stress in his life and is healthy both mentally and physically.c. He has relatively low stress in his life and use of daily relaxation can be beneficial.d. He has a moderate chance of developing a stress-related illness and can reduce this by practicing stress management.ANS: C 3. A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder?a. Depression b. Schizophreniac. Bipolar disorderd. Anxiety disorderANS: A 4. A female patient states that she has had problems with depression in the past and thinks she is depressed again. Which response by the nurse is most appropriate?a. What do you think is causing your depression this time?b. What therapies have worked for you in the past?c. Did you stop taking your medication?d. Do you think this is a situational depression?ANS: B 5. Which patient may be experiencing severe anxiety?a. A woman who tells the nurse she is terrified of catsb. A man who tells the nurse he feels worthless and is always tiredc. A woman who reports that she is sleeping very lightly each night because her child has an ear infectiond. A man who phones the nurse five times asking for instructions about how to take his new medicationANS: D F 6. While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation?a. AUDIT screening toolb. Rapid eye testc. Mental status examinationd. Holmes Social Readjustment Rating ScaleANS: A 7. A nurse screens every adult and adolescent patient for alcohol consumption. Which patient drinks more than recommended?a. The man who reports drinking 3 beers and one shot of whiskey each dayb. The woman who reports drinking 2 glasses of wine and 2 vodka martinis each dayc. The older adult man who reports drinking one glass of sherry before going to bed each nightd. The woman who reports drinking one glass of wine with lunch and dinner each day.ANS: B 8. During a sports physical for a 16-year-old girl, the nurse asks which question to collect data about drug use?a. Many teenagers have tried street drugs. Have you tried these drugs? b. Tell me which street drugs your friends have offered to you?c. Do most of your friends drink alcohol or do street drugs?d. Your high school has a reputation for drug use. Do you use drugs?ANS: A 9. In contrasting the assessment of mental status from mental health, a nurse recognizes that data for the mental status examination are obtained using which techniques?a. Asking them about their relatives who have mental health disordersb. Having them demonstrate their ability to reason and calculatec. Asking them to recall how they have coped with daily stressd. Having them describe their mood and emotionsANS: B 10. A nurse is admitting a new patient. Which statement by the patient suggests a bipolar disorder?a. The last time I had blood drawn at the office, I fainted dead away.b. No matter how hard I try, I just cant get into an elevator of any kind.c. Everyone knows I can control the financial health of this town with a snap of my fingers.d. I worked for Frank Sinatras band for several months when I lived in New Jersey years ago.ANS: C 11. During conversation, the nurse observes that the patient is talking continuously and excitedly, and is switching rapidly from one topic to another with seemingly no relationship between topics. This behavior is often associated with which disorder?a. Depressionb. Obsessive-compulsive disorderc. Schizophreniad. Bipolar disorderANS: C 12. During a visit to the clinic for an annual gynecologic examination, a patient tells the nurse that she had a bad experience on an airplane, saying, When I sat down, my heart started racing, I was short of breath and sweaty, and I felt as if I was going to die. She stated that her husband helped her to calm down after a few minutes. The nurse recognizes that the patient was describing which problem?a. Bipolar disorder, manic phaseb. Moderate anxietyc. Panicd. DelusionsANS: C 13. A patient in the waiting room appears anxious and moves around the room cleaning surfaces with a disinfectant cloth. This behavior is consistent with which disorder?a. Bipolar disorderb. Deliriumc. Schizophreniad. Obsessive-compulsive disorderANS: D 14. An elderly patient was admitted with pneumonia and a fever of 104.5 F. At the time of admission he was confused, disoriented, restless, and tried to slap the nurse who started an intravenous line. His daughter stated, Just yesterday he was perfectly fine, except for a cold. I cant believe he is acting this way now. Within a few days, his erratic behavior subsided and his daughter was relieved that he was back to normal. The nurse recognizes that this patient was exhibiting signs of which disorder?a. Dementiab. Deliriumc. Panic attackd. Alcohol withdrawalANS: B 15. During a report, a nurse hears about a patient who was admitted at 8 PM after an automobile accident. He had a blood alcohol level of 100 mg/dl at the time of admission. During the 8 AM assessment, the nurse notes that the patient is having hand tremors, is sweaty, is slightly agitated, and complains of nausea. The nurse recognizes that the patient may be exhibiting signs of which disorder?a. Alcohol withdrawal syndromeb. Delirium tremensc. Panicd. DeliriumANS: A MULTIPLE RESPONSE 1. Which neurotransmitters are decreased in patients with depression? Select all that apply.a. Acetylcholine (Ach)b. Histaminec. Norepinephrine (NE)d. Dopamine (DA)e. Gamma aminobutyric acid (GABA)\f. Serotonin (5 HT)ANS: B, C, D, FCorrect: Histamine, norepinephrine (NE), dopamine (DA), and serotonin (5 HT) are neurotransmitters that are decreased in depression. Drugs prescribed for people with depression may provide therapy by increasing these neurotransmitters.Incorrect: Acetylcholine (Ach) is increased in depression. Gamma aminobutyric acid (GABA) is decreased in schizophrenia and anxiety states. DIF: Cognitive Level: Understand REF: 66TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts 2. During a mental health history, the nurse suspects altered mental status for a patient. Which questions are appropriate to ask when assessing mental status? Select all that apply.a. Do you have difficulty making decisions?b. Do you know where you are?c. Are there times when you wanted to escape?d. If you bought a hat for $5.75 and gave the sales person $10.00, how much change do you expect back?e. What would you do if a fire started in your home?f. What does this phrase A rolling stone gathers no moss mean?ANS: B, D, E, FCorrect: Do you know where you are? assesses orientation. If you bought a hat for $5.75 and gave the sales person $10.00, how much change do you expect back? assesses calculation ability. What would you do if a fire started in your home? assesses judgment. What does this phrase A rolling stone gathers no moss mean? assesses abstract reasoning.Incorrect: For the nurse to assess mental status, the patient needs to demonstrate abilities such as calculation, judgment, and abstract reasoning. DIF: Cognitive Level: Apply REF: 70-71TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts 3. While conducting a health history, the nurse asks which questions to assess for risk factors associated with depression? Select all that apply.a. Has anyone in your family ever been diagnosed with depression?b. Have you noticed a change in how much energy you have?c. Do you have crying spells?d. Do your muscles seem tense?e. Do you feel that something bad is about to happen to you?f. Do you have difficulty making decisions?ANS: A, B, C, FCorrect: These questions are related to risk factors for depression.Incorrect: Tense muscles are associated with stress and anxiety rather than depression.Feeling that something bad is about to happen relates to paranoia rather than depression. DIF: Cognitive Level: Apply REF: 68-70| 76TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts COMPLETION 1. Researchers have found that it is the ______ of a recent life event that determines a persons emotional or psychological reaction to it. ANS:PerceptionsEach culture influences how a stressful event is perceived and the acceptable ways that people of that culture are expected to respond.

echniques and Equipment

1. What is the most important nursing action to reduce transmission of microorganisms during a physical assessment?a. Clean the bell and diaphragm of the stethoscope between patients.b. Perform hand hygiene.c. Wear gloves when anticipating exposure to body fluids.d. Wear eye protection when anticipating spatter of body fluids.ANS: B 2. When examining a patient, the nurse remembers to follow which principle of Standard Precautions?a. Wear gloves throughout the entire examination of the patient.b. Wear gloves when in contact with the patients mucous membranes.c. Wear gloves to reduce the need for handwashing.d. Wear eye protection and a gown during the examination of the patient.ANS: B 3. How do nurses prevent a latex allergy?a. They use nonlatex gloves for all procedures.b. They protect their hands using oil-based hand lotion applying latex gloves.c. They use a powder-free, low-allergen latex gloves.d. They wash their hands with mild soap and dry thoroughly before applying latex gloves.ANS: C 4. Which explanation is most appropriate for a nurse preparing to palpate a patients neck?a. I need to feel for tumors in your neck.b. Im going to feel your neck for any abnormalities.c. I need to press deeply on your neck so please hold still.d. Is there any tenderness in your neck?ANS: B 5. Which nurse is performing the technique of light palpation appropriately?a. Nurse A applies the bimanual technique to determine size and location of the patients heart.b. Nurse B uses the fingertips to feel for temperature differences on the patients legs.c. Nurse C places the ulnar surface of the hands on the patients thorax to detect vibrations.d. Nurse D depresses the patients abdomen approximately 4 cm to assess pulsations.ANS: C 6. How does the nurse perform the bimanual technique of palpation to assess organs?a. Using the palmar surface of the dominant hand to press inward to a depth of about 1 cmb. Holding a light source in one hand while stroking the skin lightly with the dominant handc. Using the ulnar surfaces of both hands to press inward 4 to 5 cmd. Using both hands, one anterior and one posterior, to entrap an organ between the fingertipsANS: D 7. While assessing a patients lower extremities, the nurse suspects the lower extremities feel cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the temperatures of the lower extremities with the upper extremities?a. Using the backs (dorsum) of the hands to detect differencesb. Using the ulnar surface of the hands to detect differencesc. Using the pads of the fingers to detect differencesd. Using the palmar surface (underside) of the hands to detect differencesANS: A 8. How does a nurse assess for fluid in a patients abdomen?a. Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index finger of the pleximeter with the pad of the middle finger of the dominant handb. Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexorc. Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed, and striking that finger with the tip of the middle finger of the dominant handd. Using direct percussion by placing one hand over the abdomen and striking lightly with the other handANS: C 9. What assessment data do nurses obtain through striking a hand directly against the flank or costovertebral angle of a patients body?a. Fluid in the lungsb. Tenderness over the kidneysc. Air in the abdomend. Tenderness over the liverANS: B 10. A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patients abdomen?a. Flatnessb. Dullnessc. Resonanced. TympanyANS: D 11. The nurse is unable to hear the patients breath sounds. What checks does the nurse make of the stethoscope to determine the cause of this problem?a. Ensure the stethoscope tubing is at least 20 inches long.b. Ensure the valve is open to the diaphragm on the head of the stethoscope.c. Ensure the earpieces are pointed toward the back of the ears.d. Ensure the bell is placed firmly against the patients skin.ANS: B 12. What part of the stethoscope do nurses use to auscultate the chest?a. Press the bell firmly against the skin to hear sounds and vibrations.b. The bell of the stethoscope is used to hear breath sounds.c. The diaphragm of the stethoscope is used to hear heart sounds.d. Either the bell or the diaphragm is used to auscultate the chest.ANS: C 13. How does the nurse detect an extra heart sound in an adult?a. Using the bell of a stethoscopeb. With a pulse oximeterc. Using the diaphragm of a stethoscoped. With a Doppler ultrasound probeANS: A 14. A nurse is preparing to take a patients blood pressure. The blood pressure cuff is 5 inches wide and the patients upper arm circumference is 20 inches. How accurate will this patients blood pressure be using this blood pressure cuff?a. Accurate, the actual valueb. Higher than the actual valuec. Lower than the actual valued. Unable to determine accuracy with available dataANS: B 15. Where does the nurse attach the sensor probe of the pulse oximeter to measure a patients oxygen saturation?a. The chest over the patients heartb. Over the patients abdominal aortac. Over the patients radial pulsed. Around the patients index finger nailANS: D 16. The patient asks about the meaning of his visual assessment of 20/40 using a Snellen visual acuity chart. What is the nurses appropriate response?a. 20/40 means your vision is about two times normal.b. A person with corrected vision can see at 20 feet what you can see at 40 feet.c. A person with normal vision can see at 20 feet what you can see at 40 feet.d. A person with normal vision can see at 40 feet what you can see at 20 feet.ANS: D 17. The nurse is using the Snellen chart to assess a patients vision. The patient states that the green line on the chart is shorter than the red line. What is the interpretation of this finding?a. This patient has normal color perception and abnormal field perception.b. This patient is color blind but has normal field perception.c. This patients color perception and field perception are normal.d. This patient is color blind and has abnormal field perception.ANS: A 18. What tool does the nurse use to assess the patients near vision?a. A Snellen eye chart placed about 12 inches from the patients face.b. An ophthalmoscope with the diopter set at 0 (zero).c. A Jaeger or Rosenbaum chart placed about 2 feet from the patients face.d. A newspaper held about 14 inches from the patients face.ANS: D 19. Using an ophthalmoscope, how does the nurse bring a patients interior eye structures into focus?a. Using the red filterb. Adjusting the dioptersc. Dilating the patients pupilsd. Using the wide-beam lightANS: B 20. Which action by the nurse describes the correct technique for using an otoscope on an adult?a. Using the pneumatic attachment to observe for tympanic fluctuationb. Striking the otoscope against the hand to engagec. Instructing the adult to raise one finger when a sound is heardd. Selecting the largest size speculum that fits into the adults ear canalANS: D 21. A nurse is preparing to assess a patients ability to detect vibrations. Which piece of equipment is appropriate for this assessment?a. Reflex hammerb. Tuning forkc. Goniometerd. MonofilamentANS: B 22. To test deep tendon reflexes, the nurse uses which instrument?a. Goniometerb. Calipersc. Reflex hammerd. MonofilamentANS: C 23. A nurse is using the finger pads to palpate a patients dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next?a. Document that the dorsalis pedis pulses are not palpable.b. Have the patient stand and try again to palpate the pulses.c. Use a Doppler to detect the presence of the pulses.d. Palpate the dorsalis pedis pulses using the ulnar surface of the hand.ANS: C 24. How does the nurse detect a pulse when using a Doppler?a. The pulsation is felt.b. The pulsation is heard.c. The pulse wave is seen on a screen.d. The pulse wave is printed out on special paper.ANS: B 25. A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which instrument/tool does the nurse use to measure the degree of flexion and extension of the patients knee joints?a. Calipersb. Ruler or tape measurec. Goniometerd. DopplerANS: C 26. When does a nurse choose to use skinfold calipers when collecting assessment data?a. Calculating the patients body mass indexb. Inspecting the patients skinc. Determining the amount of the patients lean body tissued. Estimating the amount of the patients body fatANS: D 27. When does a nurse use a Pederson or Graves speculum for examination of a patient?a. To inspect the external earb. To assess the vaginal canalc. To inspect nasal passagesd. To assess the oropharynxANS: B 28. What are characteristics of an audioscope?a. Screens for hearing abilityb. Allows visualization into the ear canalc. Must be calibrated before used. Uses vibration to estimate hearing lossANS: A 29. A patient with type 2 diabetes mellitus has an infected lesion on his foot. During the history of his present illness, he reports, I had a cut on my foot, but I did not even feel it. What equipment does the nurse use to gather more data about his foot?a. A Wood lampb. Transilluminatorc. Monofilamentd. Reflex hammerANS: C 30. A patient is complaining of pain over the maxillary sinuses. Which device does the nurse use to determine if there is air or fluid in the patients sinuses?a. Magnification deviceb. Transilluminatorc. Monofilamentd. Wood lampANS: B 31. A nurse suspects that a large skin lesion on the patients forearm is a fungal infection. Which device does the nurse use to confirm his suspicion?a. Pen lightb. Magnification devicec. Transilluminatord. Wood lampANS: D

Vital Signs

1. Which body system does the nurse assess primarily by inspection?a. Respiratoryb. Gastrointestinalc. Skind. CardiovascularANS: C 2. A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom?a. Abdominal painb. Spinal deformityc. Back paind. Breathing difficultyANS: D 3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?a. The measurement at 6 AMb. The measurement at 12 PMc. The measurement at 6 PMd. The measurement at 12 AMANS: A 4. Which statement is correct regarding taking or interpreting axillary temperatures?a. Axillary temperatures should not be used in patients less than 2 years of age.b. Readings may be less accurate.c. The thermometer is left in place for no more than 3 minutes.d. The thermometer is placed in the axilla with the shoulder abducted.ANS: B 5. A temperature of 99.8 F taken in the axilla is equivalent to which temperature value taken orally?a. 100.8 Fb. 99.8 Fc. 98.8 Fd. 97.8 FANS: A 6. The nurse suspects an irregularity in the rhythm of the patients radial pulse. What is the most appropriate action for this nurse to take at this time?a. Document this rhythm as normal for the patient.b. Use a Doppler to check the brachial pulse.c. Count the patients apical pulse for a full minute.d. Count the radial pulse again for 15 seconds and multiply by 4.ANS: C 7. The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min.a. 16-month-old; 36b. 6-year-old; 20c. 14-year-old;26d. 40-year-old; 10ANS: B 8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patients temperature is 102 F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate?a. The patients temperatureb. The patients oxygen saturationc. The patients pulse rated. The patients blood pressureANS: A 9. Nurses understand that a patients diastolic pressure represents which physiologic function?a. The pressure needed to open the aortic and pulmonic valvesb. The pressure in blood vessels when the ventricles contractc. The pressure of the blood returning to the heart from the venous systemd. The pressure in blood vessels when the ventricles are relaxedANS: D 10. According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patients upper arms?a. Ankleb. Thighc. Calfd. WristANS: A 11. A patients blood pressure has been averaging 120/72 when using the upper arms. Today the nurse uses this patients thigh to measure the blood pressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120?a. A systolic reading of 110 mm Hgb. A systolic reading of 120 mm Hgc. A systolic reading of 140 mm Hgd. A systolic reading of 170 mm HgANS: C 12. A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid?a. 1 Lb. 5 Lc. 11 Ld. 24 LANS: B MULTIPLE RESPONSE 1. Which method of temperature measurement indirectly reflects inner core temperature?Select all that apply.a. Axillary temperatureb. Oral temperaturec. Tympanic temperatured. Rectal temperaturee. Temporal artery temperatureANS: B, ECorrect: Inner core temperature is measured indirectly because the probe is placed near an artery. For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature.Incorrect: For axillary, tympanic, and rectal temperatures, the probe is not placed close to any major blood vessels. DIF: Cognitive Level: Understand REF: 38TOP: Nursing Process: AssessmentMSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Which method of temperature measurement does a nurse choose when assessing children?Select all that apply.a. Axillary temperatureb. Rectal temperaturec. Temporal artery temperatured. Oral temperaturee. Tympanic membrane temperatureANS: A, C, D, ECorrect: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children.Incorrect: Rectal temperature measurement is considered safe and accurate for adults only. DIF: Cognitive Level: Apply REF: 38-39TOP: Nursing Process: AssessmentMSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 3. Which action by the nurse results in the patients blood pressure measurement being falsely high? Select all that apply.a. Using a blood pressure cuff that is too narrow for the patients upper armb. Deflating the blood pressure cuff too rapidlyc. Wrapping the blood pressure cuff too looselyd. Reinflating the blood pressure cuff before it completely deflatese. Positioning the patients arm above the level of the heartANS: A, C, D, ECorrect: Using a blood pressure cuff that is too narrow for the patients upper arm, wrapping the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the patients arm above the level of the heart all result in readings that are falsely high.Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low. DIF: Cognitive Level: Remember REF: 43TOP: Nursing Process: AssessmentMSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. Which action by the nurse results in the patients blood pressure measurement being falsely low? Select all that apply.a. Using a blood pressure cuff that is too wide for the patients armb. Not inflating the blood pressure cuff enoughc. Positioning the patients arm above the level of the heartd. Wrapping the cuff too loosely around the arme. Deflating the cuff too rapidlyANS: A, B, ECorrect: Using a blood pressure cuff that is too wide for the patients arm, not inflating the blood pressure cuff enough, and deflating the cuff too rapidly could result in a false low reading.Incorrect: Positioning the patients arm above the level of the heart and wrapping the cuff too loosely around the arm causes the blood pressure to be falsely high. DIF: Cognitive Level: Remember REF: 43TOP: Nursing Process: AssessmentMSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 5. The nurse taking a patients blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? Select all that apply.a. The patient rates pain at a level of 7 on a scale of 0 to 10.b. The cuff was reinflated before being completely deflated.c. The patient drank cold milk just before the reading.d. The time of day is late afternoon.e. The cuff is too wide for the extremity.ANS: A, B, DCorrect: Rating pain at a level of 7 on a scale of 0 to 10, reinflating the cuff before being completely deflated, and taking the reading in late afternoon are all factors that can increase blood pressure.Incorrect: Drinking cold milk just before the reading will not affect blood pressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuff makes the reading lower than it actually is rather than higher. DIF: Cognitive Level: Apply REF: 43TOP: Nursing Process: AssessmentMSC: NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments COMPLETION 1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost _____ L from fluid loss. ANS:3.6

Health History

1. Which statement or question does the nurse use during the introduction phase of the interview?a. Im here to learn more about the pain youre experiencing.b. Can you describe the pain that youre experiencing?c. I heard you say that the pain is all over your body.d. What relieves the pain you are having?ANS: A 2. Which statement is appropriate to use when beginning an interview with a new patient?a. Have you ever been a patient in this clinic before?b. What is your purpose for coming to the clinic today?c. Tell me a little about yourself and your family.d. Did you have any difficulty finding the clinic?ANS: B 3. Which statement by the nurse demonstrates a patient-centered interview?a. I need to complete this questionnaire about your medical and family history.b. The hospital requires me to complete this assessment as soon as possible.c. Tell me about the symptoms youve been having.d. Ive had the same symptoms that youve described.ANS: C 4. Which question is an example of an open-ended question?a. Have you experienced this pain before?b. Do you have someone to help you at home?c. How many times a day do you use your inhaler?d. What were you doing when you felt the pain?ANS: D 5. A nurse suspects a female patient is a victim of physical abuse. Which response is most likely to encourage the patient to confide in the nurse?a. Youve got a huge bruise on your face. Did your husband hit you?b. That bruise looks tender. I dont know how people can do that to one another.c. If your boyfriend hit you, you can get a restraining order against him.d. Ive seen women who have been hurt by boyfriends or husbands. Does anyone hit you?ANS: D 6. Which technique used by the nurse encourages a patient to continue talking during an interview?a. Laughing and smiling during conversationb. Using phrases such as Go on, and Then?c. Repeating what the patient said, but using different wordsd. Asking the patient to clarify a pointANS: B 7. During the history, the patient states that she does not use many drugs. What is the nurses appropriate response to this statement?a. Tell me about the drugs you are using currently.b. To some people six or seven is not many.c. Do you mean prescription drugs or illicit drugs?d. How often are you using these drugs?ANS: A 8. A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The nurse suspects that the patient is noncompliant with her diet. Which response by the nurse enhances data collection in this situation?a. Tell me about what foods you eat and the frequency of your mealsb. What symptoms do you notice when your blood sugar levels are high?c. You need to follow what the doctor has prescribed to manage your diseased. Tell me what you know about the cause of type 2 diabetes.ANS: A 9. A male patient tells the nurse that he rarely sleeps more than 4 hours a night and has not experienced any problems because of the lack of sleep. Which response by the nurse is most appropriate?a. That is interesting.b. Only 4 hours of sleep? How do you stay awake during the day?c. Really? Everyone needs more sleep than that.d. Did I understand that you sleep 4 hours every night?ANS: D 10. Which technique should the nurse use to obtain more data about a patients vague or ambiguous statement?a. Laughing and smiling during conversationb. Using phrases such as Go on, and Then?c. Repeating what the patient has said, but using different wordsd. Asking the patient to explain a pointANS: D 11. What does the nurse say to obtain more data about a patients vague statement about diet such as, My diets okay?a. Eating a variety of meats, fruits, and vegetables each day is important.b. Give me an example of the foods you eat in a typical day.c. Go on.d. Does your diet meet your needs or does it need improvement?ANS: B 12. While giving a history, a male patient describes several events out of order that occurred in different decades in his life. What technique does the nurse use to understand the timeline of these events?a. State the order of events as understood and ask the patient to verify the order.b. Draw conclusions about the order of events from data given.c. Ask the patient to elaborate about these events.d. Ask the patient to repeat what he said about these events.ANS: A 13. A male patient is very talkative and shares much information that is not relevant to his history or the reason for his admission. Which action by the nurse improves data collection in this situation?a. Terminate the interview.b. Use closed-ended questions.c. Ask the patient to stay on the subject.d. Ask another nurse to complete the interview.ANS: B 14. A patient answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. Which response by the nurse is appropriate in this situation?a. Dont cry! Ill come back when youve settled down.b. I only have a few more questions to ask, and then Ill leave you alone for a while.c. Everyone has ups and downs in their marriage. What problems are you having?d. I see that you are upset. Is there something youd like to discuss?ANS: D 15. During an interview, a patient begins to cry and appears angry. Which response by the nurse is most therapeutic?a. This topic prompted an emotional response, tell me what you are feeling.b. This topic does not usually cause such an emotional response.c. Calm down and tell me what is wrong.d. I will leave you alone for a few minutes so you can pull yourself together.ANS: A 16. In which situation is the nurses use of closed-ended questions most appropriate?a. When clarifying vague or conflicting datab. When obtaining a history from an overly-talkative patientc. When encouraging a patient to elaborate on details of his or her historyd. When collecting data about the current health problemANS: B 17. The nurse is interviewing a woman with her husband present. The husband answers the questions for the wife most of the time. What is the most appropriate therapeutic nursing action to hear the patients viewpoint?a. Continue the interview.b. Ask the husband to step out of the room.c. Ask another nurse to complete the interview.d. Tell the woman to speak up for herself.ANS: B 18. A female Korean patient accompanied by her husband and son comes to the emergency department (ED) complaining of abdominal pain. The patient speaks and understands Korean only. Which person is the appropriate choice for the nurse to use to get a history from this patient?a. The patients husband who speaks Korean and Englishb. The patients son who speaks Korean and Englishc. A male technician who works in the ED who speaks Korean and Englishd. A female interpreter who speaks Korean and English and is available by phoneANS: D 19. Which nurse demonstrates culturally competent care for a female patient from Russia?a. Nurse A who asks the patient about cultural factors that influence health careb. Nurse B who interacts with every patient from Russia in the same mannerc. Nurse C who learns the cultural variables of every culture, including Russiad. Nurse D who relies on her previous experience with patients from RussiaANS: A 20. For which patient is a focused health history most appropriate?a. A new patient at the health clinic for an annual examinationb. A patient admitted to the hospital with vomiting and abdominal painc. A patient at the health care providers office for a sport physicald. A patient discharged 11 months ago who is being readmitted todayANS: B 21. A patient tells the nurse at the clinic, I can never seem to get warm lately and feel tired all the time. The nurse records these data under which section of the health history?a. Past health historyb. Present health statusc. Reason for seeking care (chief complaint)d. Subjective assessment dataANS: C 22. A patient comes to the ambulatory surgery center for an elective procedure this morning. While giving the admission history, the patient states she is allergic to latex. What is the most appropriate response by the nurse at this time?a. Removing all latex products from the patients roomb. Using powdered gloves when providing care to this patientc. Informing the surgeon that the patient has type I hypersensitivity to latexd. Questioning the patient about symptoms experienced in the past with latexANS: D 23. A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a bad reaction to the last tetanus immunization. What is the most appropriate response by the nurse in this case?a. Notify the health care provider that this immunization cannot be given.b. Document that the patient is allergic to the tetanus vaccine.c. Give the vaccine after explaining that adverse reactions are rare.d. Ask the patient to describe the bad reaction to the vaccine in more detail.ANS: D 24. A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes?a. Past health historyb. Present health statusc. Reason for seeking care (chief complaint)d. History of present illnessANS: B 25. A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which question will provide data about this patients functional ability?a. When did your arthritis symptoms begin?b. How has your arthritis affected your daily life?c. Why did you come to the clinic today?d. How do you feel about your diagnosis of rheumatoid arthritis?ANS: B 26. An example of a health promotion question included in the health history is:a. Do you have any allergies?b. How often are you exercising?c. What are you doing to relieve your leg pain?d. What kind of herbs are you using?ANS: B 27. The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts sleep and has not been helped by over-the-counter cough medicines. Which question is most appropriate for the nurse to ask next?a. So what do you think is causing this persistent cough?b. Have you tried taking sleeping pills to help you sleep?c. Did you think this will just go away on its own?d. What other symptoms have you noticed related to this cough?ANS: D 1. Which data do nurses document under the heading of Past Health History? Select all that apply.a. Father has Alzheimer diseaseb. Last tetanus in 2009c. Had chicken pox as a childd. Drinks three to four beers each daye. Had a dental examination 6 months agoANS: B, C, ECorrect: Last tetanus is an immunization, chicken pox as a child is a childhood illness, and last examinations, including dental, are documented under the heading of Past Health History.Incorrect: Family History documents fathers Alzheimer disease; patient drinking three to four beers each day refers to alcohol use, which is documented under the heading Personal and Psychosocial History. DIF: Cognitive Level: Understand REF: 15-16TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications 2. Which data do nurses document under the heading of Personal and Psychosocial History? Select all that apply.a. Walks for 45 minutes each dayb. Eats meats, vegetables, and fruit at two meals dailyc. Is allergic to milk and milk productsd. Is married and has two daughters whom is he close toe. Smokes marijuana once a weekf. Grandfather died from prostate cancerANS: A, B, D, ECorrect: Walks for 45 minutes each day is documented under health promotion activity in Personal and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is documented about diet activity in Personal and Psychosocial History; is married and has two daughters whom is he close to is documented under family and social relationship activity in Personal and Psychosocial History; smokes marijuana once a week is documented under personal habits activity in Personal and Psychosocial History.Incorrect: Allergic to milk and milk products is an allergy, which is documented under the heading Present Health Status; Grandfather died from prostate cancer is documented under the heading Family History. DIF: Cognitive Level: Understand REF: 16-17TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications 3. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports breathing problems? Select all that apply.a. How long have you had this problem with your breathing?b. Do you have a family history of breathing problems?c. Does this breathing problem come and go or is it constant?d. What do you do to make your breathing better?e. How does this breathing problem affect your work or daily activities?f. How many packs of cigarettes do you smoke a day?ANS: A, C, D, ECorrect: How long have you had this problem with your breathing?, Does this breathing problem come and go or is it constant?, What do you do to make your breathing better?, and How does this breathing problem affect your work or daily activities? are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms).Incorrect: Do you have a family history of breathing problems? This question relates to the patients history; How many packs of cigarettes do you smoke a day? This question relates to the patients history. DIF: Cognitive Level: Apply REF: 15TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports headache? Select all that apply.a. Describe what the headache feels like?b. When was your last eye examination?c. What makes the headaches worse?d. How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?e. Do you have any symptoms with the headaches, such as nausea?f. When did you first notice the headaches?ANS: A, C, D, E, FCorrect: Describe what the headache feels like?, What makes the headaches worse?, How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?, Do you have any symptoms with the headaches, such as nausea?, and When did you first notice the headaches? are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms).Incorrect: When was your last eye examination? assumes that the headaches are related to a vision problem. Last eye examination is documented in the history under the heading of Past Health History. DIF: Cognitive Level: Apply REF: 15TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 5. Which questions are pertinent for a nurse to ask a patient while performing a review of the cardiovascular system? Select all that apply.a. Do you remember what your last cholesterol value was?b. Have you had chest pain or shortness of breath?c. Do you have trouble breathing when you lie down?d. Are your feet cold, numb, or do they change color?e. How much do you weigh?f. Have you noticed edema in your ankles at the end of the day?ANS: B, C, D, FCorrect: Have you had chest pain or shortness of breath?, Do you have trouble breathing when you lie down?, Are your feet cold, numb, or do they change color?, and Have you noticed edema in your ankles at the end of the day? are questions asked to give the patient an opportunity to report symptoms of the cardiovascular system.Incorrect: Do you remember what your last cholesterol value was? relates to a lab value, which is objective data not documented in the history; How much do you weigh? is objective data not documented in the history.

Pain

Chapter 6: Pain AssessmentTest Bank MULTIPLE CHOICE 1. How do nurses assess a patients pain?a. By assessing physiologic changes of the patientb. By understanding the sensory experience related to the amount of tissue damagec. By the patients medical diagnosis or surgical procedured. By asking the patient to rate the pain being experiencedANS: D 2. The nurse notes in the patients history that the patient has persistent, malignant pain. What is the meaning of this type of pain?a. The pain has been present for at least 2 weeks.b. The pain began after recent surgery and is associated with healing incisions.c. The pain has been present for 6 or more months.d. The pain has been present since surgery to remove cancer.ANS: C 3. A patient has had chronic back pain for several years. On assessment, the nurse notes that the patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be in pain. When questioned, the patient rates the pain as a 6 on a scale of 0 to 10. How does the nurse interpret these data?a. Many patients cannot be believed when they complain of severe pain lasting many months.b. Patients may not have the same objective responses to chronic pain because of compensation over time.c. The patient probably has already taken a very effective pain medication.d. This patient is probably not having as much pain as reported initially, and more assessment is required.ANS: B 4. Which patient would be expected to experience acute pain?a. A patient who had abdominal surgery 8 hours agob. A patient who has cancer and has been receiving treatment for 4 monthsc. A patient who states that he or she has lived with severe pain for many yearsd. A patient who has been treated unsuccessfully over the past year for back painANS: A 5. Which patient has pain caused by abnormal processing of sensory input from the peripheral nervous system?a. The patient who has aching pain from muscle strainb. The patient who has burning pain along the sciatic nervec. The patient who has cramping pain from a tumor in the colond. The patient who has throbbing pain from arthritisANS: B 6. A patient reports right shoulder pain that comes and goes as the chief complaint. During the physical examination, the patient asks why the upper right abdomen is being examined for shoulder pain. What is the appropriate response from the nurse?a. A comprehensive examination is required to determine the cause of your pain.b. There may be associated problems that have not produced any symptoms yet that we want to identify.c. Yes, this can be confusing, but if you will be patient Im sure we can find something to help you.d. It does seem odd, but the gallbladder doesnt have pain receptors of its own, so the pain shows up in the shoulder.ANS: D 7. A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, How I can be feeling pain in my footmy foot is gone! What is the appropriate response from the nurse?a. After your amputation, pain perception increases.b. Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system.c. Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there.d. When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located.ANS: C 8. A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a scale of 0 to 10. The nurse completes an assessment of this patients pain and agrees to give pain medication. When the nurse returns to the patient with the ordered intravenous pain medication, she notices the patients eyes are closed and he appears to be sleeping. What is the nurses appropriate action at this time?a. Lock up the medication in a safe location until the patient awakens.b. Arouse the patient to confirm he still wants the medication.c. Give the medication as ordered and agreed to.d. Consult a colleague about what action to take.ANS: C 9. In the labor and delivery department, the nurse notices that two women who are in labor are responding differently to their contractions. The first woman, who is having her first baby, has rated her pain as a 7, seems agitated, and has asked for pain medication. The second woman, who is having her third baby, has also rated her pain as a 7, but is calmer and says she does not need anything for pain at this time. What explains the differences in the outward responses to pain between these women?a. Pain toleranceb. Pain thresholdc. Nociceptiond. Physiologic stressANS: A 10. A patient admitted to the emergency department with excruciating chest pain, above the rating of 10, has a heart rate of 55, rapid, irregular respirations, complains of nausea, and is too weak to move to the stretcher without aid. The nurse recognizes that this response to severe pain is due to the response of the _____ nervous system.a. Parasympatheticb. Sympatheticc. Centrald. PeripheralANS: A 11. A patient with gout is complaining of severe, throbbing pain in the great toe. What type of pain is this patient experiencing?a. Neuropathic painb. Somatic painc. Referred paind. Visceral painANS: B 12. A patient with a partial small bowel obstruction describes the pain as cramping, off-and-on pain that spreads over my stomach. What type of pain is this patient experiencing?a. Referred painb. Phantom painc. Somatic paind. Visceral painANS: D 1. A nurse is assessing a patient who complains of awful abdominal pain and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? Select all that apply.a. Tachycardiab. Irritabilityc. Increased blood pressured. Depressione. Insomniaf. SweatingANS: A, C, FCorrect: The sympathetic nervous system responds to acute pain by increasing heart rate, increasing blood pressure, causing diaphoresis, increasing respiratory rate, increasing muscle tension, dilating pupils, and decreasing gastrointestinal motility.Incorrect: Irritability, depression, and insomnia are manifestations of chronic rather than acute pain. DIF: Cognitive Level: Apply REF: 59| 63TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. The nurse is performing a symptom analysis of a patient with pain. Which questions below are appropriate for a symptom analysis? Select all that apply.a. Have you had any other symptoms such as nausea, vomiting, and sweating?b. Where is the pain located?c. Have you had a pain like this before?d. What does the pain feel like?e. What do you do to make your pain better?f. In your culture, how are you encouraged to express your pain?ANS: A, B, D, ECorrect: Have you had any other symptoms such as nausea, vomiting, and sweating? Where is the pain located? What does the pain feel like? What do you do to make your pain better? These four questions are asked in a symptom analysis that includes the following variables: onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, self-treatment, and severity.Incorrect: Have you had a pain like this before? This question relates to the patients health history. In your culture, how are you encouraged to express your pain? This question relates to the patients culture and does not help analyze the patients pain experience. DIF: Cognitive Level: Apply REF: 59-60TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 3. How do nurses assess pain of neonates or of adults with dementia or decreased level of consciousness? Select all that apply.a. Ask family or caregivers what indicators they think may indicate the patients pain.b. Review results of blood tests for signs of pain.c. Administer the ordered analgesic to the patient.d. Identify any physiologic signs of pain.e. Examine the patient for possible causes of pain.ANS: A, C, D, ECorrect: These four answers are the clinical practice recommendations of Herr and colleagues.Incorrect: Pain cannot be detected with laboratory tests. DIF: Cognitive Level: Understand REF: 62TOP: Nursing Process: AssessmentMSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Assessing Pain