Physical Assessment Final

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to: 1. use a cotton-tipped swab to dry the ear canals thoroughly after each swim. 2. use rubbing alcohol or 2% acetic acid eardrops after every swim. 3. irrigate the ears with warm water and a bulb syringe after each swim. 4. rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.

2

A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate calories and appears well nourished. In further assessing her, what would the nurse expect to find? 1.Poor skin turgor 2.Decreased serum albumin 3.Increased lymphocyte count 4.Triceps skinfold less than standard

2

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: 1. is normal for people of that age. 2. is a characteristic of recruitment. 3. may indicate a middle ear infection. 4. indicates that the patient has a cerumen impaction.

2

A mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and increase in appetite. Which of the following represents information the nurse should discuss with them? 1.The necessity of exercise and dieting at this age 2.Suggestions for snacks high in protein, iron, and calcium 3.Teenagers who have a weight problem should not be allowed to snack 4.The importance of a low-calorie diet to prevent the accumulation of fat

2

A patient in her first trimester of pregnancy is diagnosed with rubella. The nurse recognizes that the significance of this in relation to the infant's hearing is which of the following? 1. Rubella may affect the mother's hearing but not the infant's. 2. Rubella can damage the infant's organ of Corti, which will impair hearing. 3. Rubella is only dangerous to the infant in the second trimester of pregnancy. 4. Rubella can impair the development of CN VIII and thus affect hearing.

2

A patient tells the nurse that his food just doesn't have any taste anymore. The nurse's best response would be: 1."That must be really frustrating." 2."When did you first notice this change?" 3."My food doesn't always have a lot of taste either." 4."Sometimes that happens but your taste will come back."

2

During a nutritional assessment of a 22-year-old male refugee, the nurse must remember to: 1.obtain a 24-hour dietary recall. 2.clarify what is meant by the term "food." 3.provide him with a standard dietary handbook. 4.assume that his diet is consistent with other refugees from the same country.

2

During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color. This is an indication of: 1.iron deficiency. 2.riboflavin deficiency. 3.vitamin D and calcium deficiency. 4.vitamin C deficiency.

2

In performing a voice test to assess hearing, which of the following would the nurse do? 1. Shield the lips so that the sound is muffled. 2. Whisper two-syllable words and ask the patient to repeat them. 3. Ask the patient to place his finger in his ear to occlude outside noise. 4. Stand about 4 feet away to ensure that the patient can really hear at this distance.

2

In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which of the following data would the nurse expect to find? 1.An increase in hair growth 2.Inadequate food intake 3.Weight 10% to 20% over ideal 4.Sore, inflamed buccal cavity

2

The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? 1. If the drum has ruptured, there will be purulent drainage. 2. Bloody or clear watery drainage can indicate a basal skull fracture. 3. The auditory canal many be occluded from increased cerumen. 4. There may be occlusion of the canal caused by foreign bodies from the accident.

2

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: 1. refer the patient for the possibility of a fungal infection. 2. know that these are scars caused from frequent ear infections. 3. consider that these findings may represent the presence of blood in the middle ear. 4. be concerned about the ability to hear because of this abnormality on the tympanic membrane.

2

The nurse needs to determine the body mass index of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? 1.Changes in fat distribution will affect the waist-to-hip ratio. 2.Height measurements may not be accurate because of changes in bone. 3.Declining muscle mass will affect the triceps skinfold measure. 4.Mid arm circumference is difficult to obtain because of loss of skin elasticity.

2

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of the following findings of the tympanic membrane? 1. Red and bulging 2. Hypomobility 3. Retraction with landmarks clearly visible 4. Flat, slightly pulled in at the center, and moves with insufflation

2

When evaluating the results of laboratory tests, the nurse knows that which of the following statements is true? 1.Normal values do not vary according to age. 2.Variations based on biocultural differences may exist. 3.It is not necessary to repeat laboratory tests once malnutrition has been determined. 4.Lab tests are more sensitive than other parts of the assessment and should take priority.

2

When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear: 1. light pink with a slight bulge. 2. pearly gray and slightly concave. 3. pulled in at the base of the cone of light. 4. whitish with a small fleck of light in the superior portion.

2

Which of the following factors is most likely to affect the nutritional status of an 82-year-old person? 1.Increase in taste and smell 2.Living alone on a fixed income 3.Change in cardiovascular status 4.Increase in gastrointestinal motility and absorption

2

Which of the following statements is true concerning the nutritional assessment? 1.It is only useful in patients who are overweight. 2.It identifies patients who are at risk of malnutrition. 3.This assessment can only be thoroughly done by a dietician. 4.It provides the nurse with physical findings related to all the systems.

2

While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is: 1. fungal infection. 2. acute otitis media. 3. rupture of the drum. 4. blood behind the drum.

2

The nurse is assessing an obese patient for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of the following are risk factors for metabolic syndrome? Select all that apply. 1.Fasting plasma glucose level less than 110 mg/dl 2.Fasting plasma glucose level greater than or equal to 100 mg/dl 3.Blood pressure reading of 140/90 mm/Hg 4.Blood pressure reading of 110/80 mm/Hg 5.Triglyceride level of 120 mg/dl

2, 3

29. During a hearing assessment the nurse finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse conclude from this? 1. The patient has a conductive hearing loss in the right ear. 2. Lateralization is a normal finding with the Weber test. 3. The patient could have either a sensorineural or a conductive loss. 4. A mistake has occurred; the test must be repeated.

3

42. A 65-year-old man is brought to the emergency department after he was found dazed and incoherent, alone in his apartment. He has an enlarged liver and is moderately dehydrated. When evaluating his serum albumin level, the nurse must keep in mind that: 1.serum albumin levels will increase as liver function decreases. 2.serum albumin levels are a sensitive measure of early protein malnutrition. 3.low serum albumin levels may be caused by reasons other than protein-calorie malnutrition. 4.the results of the serum albumin measurement along with the patient's hemoglobin level should be considered.

3

A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which of the following is most appropriate when collecting current dietary intake information? 1.Schedule a time for direct observation of the adolescent during meals. 2.Ask the patient for a 24-hour diet recall and assume this is reflective of a typical day for her. 3.Have the patient complete a food diary for 3 days—2 weekdays and 1 weekend day. 4.Use the food frequency questionnaire to identify the amount of intake of specific foods.

3

A 50-year-old woman with elevated serum, total cholesterol, and triglyceride levels is visiting the clinic today to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests? 1.The risks of undernutrition 2.Methods to reduce stress in her life 3.Information regarding a low saturated fat diet 4.The fact that this is hereditary and there is nothing she can do to change the levels

3

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? 1. Atrophy of the apocrine glands 2. Cilia becoming coarse and stiff 3. Nerve degeneration in the inner ear 4. Scarring of the tympanic membrane

3

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: 1. speak loudly so he can hear the questions. 2. assess for middle ear infection as a possible cause. 3. ask the patient what medications he is currently taking. 4. look for the source of the obstruction in the external ear.

3

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: 1. maintain balance. 2. interpret sounds as they enter the ear. 3. conduct vibrations of sounds to the inner ear. 4. increase amplitude of sound for the inner ear to function.

3

A pregnant woman who is human immunodeficiency virus (HIV) positive is asking the nurse about breast-feeding her baby. Which of the following statement is true? 1.There is not enough information to know whether it would be safe for her to breast-feed. 2.It is safe for women who are HIV positive to breast-feed. 3.Women who are HIV positive should not breast-feed because HIV can be transmitted through breast milk. 4.She can breastfeed as long as she uses pumped breast milk.

3

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? 1. This is probably the result of lesions from eczema in his ear. 2. This represents poor hygiene. 3. This is a normal finding and no further follow-up is necessary. 4. This could be indicative of change in cilia; the nurse should assess for conductive hearing loss.

3

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom is: 1. vertigo. 2. pruritus. 3. tinnitus. 4. cholesteatoma.

3

The mother of an 8-year-old boy is concerned about the amount of weight her son has gained. To determine whether this is a problem, the nurse will measure: 1.arm span. 2.waist-to-hip ratio. 3.skinfold thickness. 4.mid upper arm circumference.

3

The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of the following problems related to his nutritional status might the nurse expect to find? 1.Obesity 2.Hypotension 3.Osteomalacia 4.Coronary artery disease

3

The nurse is concerned about the skeletal protein reserves of a patient who has been hospitalized frequently for chronic lung disease. Which of the following measurements would be necessary to include in the assessment? 1.Body mass index 2.Weight and height 3.Mid arm muscle area 4.Ideal body weight and frame size

3

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct? 1. Sticky honey-colored cerumen is a sign of infection. 2. The presence of cerumen is indicative of poor hygiene. 3. The purpose of cerumen is to protect and lubricate the ear. 4. Cerumen is necessary for transmitting sound through the auditory canal.

3

The nurse is performing an assessment on a 65-year-old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: 1. is most likely a benign sebaceous cyst. 2. is most likely a Darwin's tubercle and is not significant. 3. could be a potential carcinoma and should be referred. 4. is a tophus, which is common in the elderly and is a sign of gout.

3

The nurse is performing an otoscopic examination on an adult. Which of the following is true? 1. Tilt the person's head forward during the exam. 2. Once the speculum is in the ear, release the traction. 3. Pull the pinna up and back before inserting the speculum. 4. Use the smallest speculum to decrease the amount of discomfort.

3

To obtain an accurate nitrogen balance and creatinine-height index, the nurse must ensure that: 1.the patient's height and weight have been determined. 2.the laboratory draws the blood specimen in the early morning. 3.an accurate 24-hour urine specimen has been collected. 4.the patient has not had anything by mouth for 8 hours before the test.

3

To perform a triceps skinfold assessment, the examiner would do which of the following? 1.After pinching the skin and fat, apply the calipers vertically to the fat fold. 2.Gently pinch the skin and fat on the anterior aspect of the patient's arm and then apply calipers. 3.After applying the calipers, wait 3 seconds before taking a reading. Repeat the procedure three times. 4.Instruct the patient to stand with the back to the examiner and arms folded across the chest and pinch the skin on the forearm.

3

When the mid upper arm circumference and triceps skinfold of an 82-year- old man are evaluated, it is important to remember that: 1.these measurements are no longer necessary for the elderly. 2.derived weight measures may be difficult to interpret because of wide ranges of normal. 3.these measurements may not be accurate because of changes in skin and fat distribution. 4.measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.

3

Which of the following conditions is due to an inadequate intake of both protein and calories? 1.Obesity 2.Bulimia 3.Marasmus 4.Kwashiorkor

3

Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? 1. CN I 2. CN III 3. CN VIII 4. CN XI

3

Which of the following interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? 1.Decrease the amount of carbohydrates to prevent lean muscle catabolism. 2.Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis. 3.Decrease the number of calories she is eating because of the decrease in energy requirements from loss of lean body mass. 4.Increase the number of calories she is eating because of the increased energy needs of the elderly.

3

Which of the following statements is true regarding routine laboratory testing in the following individuals 1.In pregnancy, no laboratory testing is needed unless problems with the pregnancy are suspected. 2.In the elderly, laboratory values regarding cholesterol and triglycerides are the most important because of the risk of disease. 3.During adolescence, unless disease is suspected, laboratory evaluation of hemoglobin and hematocrit levels and urinalysis for glucose and protein are adequate. 4.In infancy and childhood, laboratory tests should be performed at each well-child check-up, regardless of whether the child is exhibiting signs of illness that affect nutritional status.

3

Which of the following would be true regarding otoscopic examination of a newborn? 1. Immobility of the drum is a normal finding. 2. An injected membrane would indicate infection. 3. The normal membrane may appear thick and opaque. 4. The appearance of the membrane is identical to that of an adult.

3

A full mental status examination should be completed if the patient: a. has a change in behavior and the family is concerned b. develops dysphagia c. has a new diagnosis of type 2 diabetes mellitus d. complains of insomnia

A

A major characteristic of dementia is: a. impaired short-term and long-term memory b. hallucinations c. sudden onset of symptoms d. cognitive deficits that are substance-induced

A

A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the: a. Testes. b. Prostate. c. Epididymis. d. Vas deferens.

A

A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a.Appear unhurried and confident when examining him. b.Stay in the room when he undresses in case he needs assistance. c.Ask him to change into an examining gown and to take off his undergarments. d.Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

A

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 101 degrees F. She has also had symptoms of the flu, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget's disease c. Plugged milk duct d. Mammary duct ectasia

A

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: a. Has a snake phobia. b. Is a hypochondriac; snakes are usually harmless. c. Has an obsession with snakes. d. Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.

A

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient's level of consciousness would be: a. Lethargic b. Obtunded c. Stuporous d. Semialert

A

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."

A

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: a. Nonpitting, hard edema occurs with lymphatic obstruction. b. Alterations in arterial function will cause edema. c. Phlebitis of a superficial vein will cause bilateral edema. d. Long-standing arterial obstruction will cause pitting edema.

A

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to: a. Plan to defer the rest of the mental status examination. b. Skip the language portion of the examination, and proceed onto assessing mood and affect. c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time. d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

A

A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure. b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure because her complete health history was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed.

A

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? A) Crepitation B) A bone spur C) A loose tendon D) Fluid in the knee joint

A

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

A

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? a. "Can you point to where it hurts?" b. "We'll talk more about that later in the interview." c. "What have you had to eat in the last 24 hours?" d. "Have you ever had any surgeries on your abdomen?"

A

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.

A

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.

A

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.

A

A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and report this immediately. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.

A

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: A) menstrual history because it is generally nonthreatening. B) obstetric history because it is the most important information. C) urinary system history because there may be problems in this area as well. D) sexual history because it will build rapport to discuss this first.

A

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.

A

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: a. Asthma. b. Atelectasis. c. Lobar pneumonia. d. Heart failure.

A

An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be attributable to: a. Side effects of medications. b. Decreased libido with aging. c. Decreased sperm production. d. Decreased pleasure from sexual intercourse.

A

Aphasia is best described as: a. a language disturbance in speaking, writing, or understanding b. the impaired ability to carry out motor activities despite intact motor function c. the impaired ability to recognize or identify objects despite intact sensory function d. a disturbance in executive functioning (planning, organizing, sequencing, abstracting)

A

During a cardiovascular assessment, the nurse knows that a "thrill" is: a. Vibration that is palpable. b. Palpated in the right epigastric area. c. Associated with ventricular hypertrophy. d. Murmur auscultated at the third intercostal space.

A

During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be: A) broccoli. B) hamburger. C) iceberg lettuce. D) yogurt.

A

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a. "How do you feel today?" b. "Would you please repeat the following words?" c. "Have these medications had any effect on your pain?" d. "Has this pain affected your ability to get dressed by yourself?"

A

During a physical examination, the nurse finds that a male patient's foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is: a. Phimosis. b. Epispadias. c. Urethral stricture. d. Peyronie disease.

A

During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal? A) Cervix B) Uterus C) Ovaries D) Fallopian tubes

A

During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which of these conditions? A) Candidiasis B) Trichomoniasis C) Atrophic vaginitis D) Bacterial vaginosis

A

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test? a.Ascites b.Splenomegaly c.Constipation d.Distended bladder

A

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

A

During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this? a.Projectile vomiting b.Hypoactive bowel activity c.Palpable olive-sized mass in the right lower quadrant d.Pronounced peristaltic waves crossing from right to left

A

During an examination the nurse observes a female patient's vestibule and expects to see the: A) urethral meatus and vaginal orifice. B) vaginal orifice and vestibular (Bartholin) glands. C) urethral meatus and paraurethral (Skene) glands. D) paraurethral (Skene) and vestibular (Bartholin) glands.

A

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

A

1. A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? a. Dilated pupils, pacing, and psychomotor agitation b. Dilated pupils, unsteady gait, and aggressiveness c. Pupil constriction, lethargy, apathy, and dysphoria d. Constricted pupils, euphoria, and decreased temperature

A

11. The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? a. Perception b. Modulation c. Transduction d. Transmission

A

13. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Avoiding touching the nasal septum with the speculum b. Inserting the speculum at least 3 cm into the vestibule c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

A

17. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. What do these findings indicate? a. Dehydration b. A normal oral assessment c. Irritation from gastric juices d. Side effects from nausea medication

A

2. The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as: a. Hypertension. b. Ventricular fibrillation. c. Bradycardia. d. Mitral valve prolapse.

A

21. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland

A

26. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. What do these findings indicate? a. Candidiasis b. Leukoplakia c. Koplik spots d. Aphthous ulcers

A

27. When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a. Ear dysplasia. b. Long, thin neck. c. Protruding thin tongue. d. Narrow and raised nasal bridge.

A

33. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a. Allergies. b. Sinus infection. c. Nasal congestion. d. Upper respiratory infection.

A

During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. It is a normal variation and not a significant finding. b. It is a significant finding and needs further investigation. c. It also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correct-it is actually a mole that happens to be located under the breast.

A

During an examination, which tests will the nurse collect to screen for cervical cancer? A) Endocervical specimen, cervical scrape, and vaginal pool B) Endocervical specimen, vaginal pool, and acetic acid wash C) Endocervical specimen, KOH preparation, and acetic acid wash D) Cervical scrape, acetic acid wash, saline mount ("wet prep")

A

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? a. Listening to at least one full respiration in each location b. Listening as the patient inhales and then going to the next site during exhalation c. Instructing the patient to breathe in and out rapidly while listening to the breath sounds d. If the patient is modest, listening to sounds over his or her clothing or hospital gown

A

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When the bronchial tree is obstructed b. When adventitious sounds are present c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia

A

During inspiration, intrathoracic pressure is decreased and causes which of the following to occur? A. An increase in blood return to the right side of the heart B. Early closing of the mitral valve C. A greater pressure is needed to open the aortic valve. D. An increase in blood return to the left side of the heart

A

36. During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. Which is the best response by the nurse? a. "You should never use over-the-counter nasal sprays because of the risk for addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling."

A

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: a. Echolalia b. Clanging c. Word salad d. Perseveration

A

37. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between ones thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

A

37. During an oral examination of a 4-year-old American-Indian child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. A bifid uvula may occur in some American-Indian groups. b. This condition is a cleft palate and is common in American Indians. c. A bifid uvula is torus palatinus, which frequently occurs in American Indians. d. This condition is due to an injury and should be reported to the authorities.

A

38. During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. Head control is usually achieved by 4 months of age. b. You shouldnt be trying to pull your baby up like that until she is older. c. Head control should be achieved by this time. d. This inability indicates possible nerve damage to the neck muscles.

A

39. During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should: a. Continue the examination because a bruit is a normal finding for this age. b. Check for the bruit again in 1 hour. c. Notify the parents that a bruit has been detected in their child. d. Stop the examination, and notify the physician.

A

7. When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory.

A

8. A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland. a. Thyroid b. Parotid c. Adrenal d. Parathyroid

A

A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: a. she began to develop breasts b. her mother developed breasts c. she began to develop pubic hair d. she began to develop axillary hair.

A

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object

A

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

A

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

A

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

A

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? a. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change. b. Because of increased cardiac output, the blood pressure should be higher at this time. c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output. d. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.

A

A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." *The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is:* a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be related to your menstrual cycles. Keep track of changes in the mass each month." c. "This is probably nothing to worry about because it has been present for years and was determined to be noncancerous at that time." d. "Because you are experiencing no pain and the size has not changed, continue to monitor the lump and return to the clinic in 3 months."

A

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

A

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

A

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: a. Dysuria. b. Nocturia. c. Polyuria. d. Hematuria.

A

During the change-of-shift report, the student nurse hears that a patient has hepatomegaly. What should the student recognizes that this term means? a.Enlarged liver b.Enlarged spleen c.Distended bowel d.Excessive diarrheaANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

A

A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a.Auscultate the lungs and heart while the infant is still sleeping. b.Examine the infant's hips, because this procedure is uncomfortable. c.Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach. d.Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.

A

A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which of the following? A) Prostatitis B) A polyp C) Carcinoma of the prostate D) Benign prostatic hypertrophy (BPH)

A

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: a. Claudication. b. Sore muscles. c. Muscle cramps. d. Venous insufficiency.

A

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.

A

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

A

A 70-year-old man is visiting the clinic for difficulty in passing urine. In the history he indicates he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Given this history, what might the nurse expect to find during the physical assessment? A) Asymmetric, hard, fixed prostate gland B) Occult blood and perianal pain to palpation C) Symmetrically enlarged, soft prostate gland D) A soft nodule protruding from rectal mucosa

A

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds

A

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

A

How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema

A

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

A

In previewing the medical record of a patient, you find documentation of pulsus alternans. On the basis of this fact, what do you expect when you assess the patient? Pulse with a regular rhythm, but the force of the pulse varies with alternating beats. Pulse with weaker amplitude with respiratory inspiration and stronger amplitude with expiration. Deficiency of oxygenated arterial blood to a body part. Pulse with coupled rhythm; every other beat is premature.

A

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a."It should fall off in 10 to 14 days." b."It will soften before it falls off." c."It contains two veins and one artery." d."Skin will cover the area within 1 week."

A

Mental status assessment documents: a. emotional and cognitive functioning b. intelligence and educational level c. artistic or writing ability in the mentally ill person d. schizophrenia and other mental health disorders

A

Mr. Kimbel is a 59-year-old patient who comes to the clinic for a routine health assessment at the request of his son. On examination, you note a positive profile sign. This indicates: a. early clubbing. b. the patency of the radial and ulnar arteries. c. the presence of thrombophlebitis. d. the degree of pedal edema.

A

Mr. Worrigan is a 67-year-old patient who comes with his son to the ambulatory health centre. On examination of Mr. Worrigan, you note a pulsus alternans. This is associated with: a. heart failure. b. pulmonary embolisms. c. hyperkinetic states. d. decreased cardiac output.

A

Mrs. Wysnicki brings her newborn infant into the ambulatory health centre for a health assessment. When auscultating the heart of a newborn, you hear a continuous sound that mimics the sound of a machine. Based on your knowledge of newborn cardiac physiology, you know that this: A. is an expected sound due to nonclosure of the ductus arteriosus. B. is a normal sound due to the thinner chest wall of the newborn. C. is highly suspicious for the presence of congenital heart disease. D. sound is only pathological when accompanied by an increased heart rate.

A

Ms. Kelson is a 26-year-old patient who comes to the clinic for a routine health assessment. On examination, you note a fixed split. Which is a characteristic of this finding? A. It is unaffected by respiration. B. It is only heard with the bell of the stethoscope. C. It generally only occurs with S1. D. It is more than likely to be pathological.

A

Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.

A

Of what does the patient believe the amulet is protective? a. the evil eye b. being kidnapped c. exposure to bacterial infections d. an unexpected fall.

A

The QRS complex of the ECG represents: a. ventricular depolarization. b. atrial depolarization. c. ventricular repolarization. d. an impulse passing through the AV node.

A

The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.

A

The cardiac output is defined as the: A. amount of blood pumped by the heart in 1 minute. B. amount of blood returned to the heart. C. amount of blood ejected with each contraction. D. ability of the heart to pump blood.

A

The direction of blood flow through the heart is best described by which of these? a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle

A

The first heart sound is caused by closure of the: A. AV valves. B. semilunar valves. C. right-sided valves. D. left-sided valves.

A

The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.

A

The leaflets of the tricuspid and mitral valves are anchored by __________________ to the _________________, which are embedded in the ventricular floor. A. chordae tendineae; papillary muscles B. pericardial cords; ventricular sheaths C. endocardial ligaments; mediastinal muscles D. AV tendon of Todaro; pericardial bundles

A

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? a. Tetralogy of Fallot b. Atrial septal defect c. Patent ductus arteriosus d. Ventricular septal defect

A

The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment, the nurse finds redness and raised skin in the anal area. This most likely indicates: A) pinworms. B) chickenpox. C) constipation. D) bacterial infection.

A

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global b. Broca's c. Dysphonic d. Wernicke's

A

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a. Cognitive impairment b. Amnesia c. Delirium d. Attention-deficit disorder

A

The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100° F

A

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: a. Normal for this age. b. Lower than expected. c. Higher than expected, probably as a result of crying. d. Higher than expected, reflecting persistent tachycardia.

A

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes.

A

The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. The nurse recognizes that this is important because: A) this stool would indicate anal patency. B) the dark green color could indicate occult blood in the stool. C) meconium stool can be reflective of distress in the newborn. D) the newborn should have passed the first stool within 12 hours after birth.

A

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion

A

The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is: a. the same day every month. b. daily, during the shower or bath. c. 1 week after her menstrual period. d. every year with her annual gynecologic examination.

A

The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.

A

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

A

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. Presence of pigmented crescents in the macular area d. Presence of the macula located on the nasal side of the retina

A

The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation? a. Skin on the scrotum is taut. b. Left testicle hangs lower than the right testicle. c. Scrotal skin has yellowish 1-cm nodules that are firm and nontender. d. Testes move closer to the body in response to cold temperatures.

A

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchial sounds c. Bronchophony d. Whispered pectoriloquy

A

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. a. Side-to-side b. Top-to-bottom c. Posterior-to-anterior d. Interspace-by-interspace

A

The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. "Do you perform testicular self-examinations?" b. "Have you ever noticed any pain in your testicles?" c. "Have you had any problems with passing urine?" d. "Do you have any history of sexually transmitted diseases?"

A

The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with arms raised over her head b. Sitting with arms relaxed at the sides c. Supine with arms relaxed at the sides d. Sitting with arms flexed and fingertips touching shoulders

A

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a. Dullness. b. Tympany. c. Resonance. d. Hyperresonance.

A

The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. Do you take medicine? b. Do you sterilize the bottles? c. Do you have nausea and vomiting? d. You have been taking your medicine, havent you?

A

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

A

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? a. Blacks b. Whites c. American Indians d. Hispanics

A

The nurse is preparing to interview a postmenopausal woman. Which of these statements is true with regard to the history of a postmenopausal woman? A) The nurse should ask a postmenopausal woman if she ever has vaginal bleeding. B) Once a woman reaches menopause, the nurse does not need to ask any further history questions. C) The nurse should screen for monthly breast tenderness. D) Postmenopausal women are not at risk for contracting sexually transmitted infections and thus these questions can be omitted.

A

The nurse is preparing to palpate the rectum and should use which of these techniques? A) Flex the finger and insert slowly toward the umbilicus. B) Instruct the patient first that this will be a painful procedure. C) Insert an extended index finger at a right angle to the anus. D) Place the finger directly into the anus to overcome the tight sphincter.

A

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a.Is used to listen for high-pitched sounds. b.Is used to listen for low-pitched sounds. c.Should be lightly held against the person's skin to block out low-pitched sounds. d.Should be lightly held against the person's skin to listen for extra heart sounds and murmurs.

A

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

A

The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a.Percussing once over each area b.Quickly lifting the striking finger after each stroke c.Striking with the fingertip, not the finger pad d.Using the wrist to make the strikes, not the arm

A

The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer? a. African-American b. White c. Asian d. American Indian

A

The nurse is reviewing the changes that occur with menopause. Which of these are changes associated with menopause? A) Uterine and ovarian atrophy along with thinning vaginal epithelium B) Ovarian atrophy, increased vaginal secretions, and increasing clitoral size C) Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions D) Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine hypertrophy

A

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

A

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."

A

The nurse is testing a patient's visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light

A

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

A

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

A

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

A

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. a. Nursing b. Medical c. Admission d. Collaborative

A

The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test

A

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a.Palpation b.Inspection c.Percussion d.Auscultation

A

The primary muscles of respiration include the: a. Diaphragm and intercostals. b. Sternomastoids and scaleni. c. Trapezii and rectus abdominis. d. External obliques and pectoralis major.

A

The sac that surrounds and protects the heart is called the: a. Pericardium. b. Myocardium. c. Endocardium. d. Pleural space.

A

The uterus is usually positioned tilting forward and superior to the bladder. This position is known as: A) anteverted and anteflexed. B) retroverted and anteflexed. C) retroverted and retroflexed. D) superiorverted and anteflexed.

A

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

A

When assessing a patient's lungs, the nurse recalls that the left lung: a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

A

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side

A

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure.

A

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a.Spleen b.Appendix c.Gallbladder d.Sigmoid colon

A

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a.Consider this a normal finding. b.Palpate this area for an underlying mass. c.Reposition the hands, and attempt to percuss in this area again. d.Consider this finding as abnormal, and refer the patient for additional treatment.

A

When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is: a. Called hypospadias. b. A result of phimosis. c. Probably due to a stricture. d. Often associated with aging.

A

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.

A

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: a. Consider this a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings.

A

When preparing to perform a physical examination on an infant, the nurse should: a.Have the parent remove all clothing except the diaper on a boy. b.Instruct the parent to feed the infant immediately before the examination. c.Encourage the infant to suck on a pacifier during the abdominal examination. d.Ask the parent to leave the room briefly when assessing the infant's vital signs.

A

When providing his health history, Mr. Meier sates that his mother had lymphedema and then says, "Just what is that?" Your best reply would be that lymphedema is: a. the swelling of an extremity due to an obstructed lymph channel. b. an inflammation of the vein associated with thrombus formation. c. the indentation left after the examiner depresses the skin over swollen edematous tissue. d. a thickening and loss of elasticity of the arterial walls.

A

Which factor is identified as a priority influence on a patient's health status? a. poverty b. lifestyle factors c. legislative action d. occupational status

A

Which of the following statements regarding the sound produced by heart valves is true? A. The sound produced radiates in the direction of blood flow. B. The intensity of the sound produced is directly related to the stroke volume. C. Heart valve sounds are best heard over the exact anatomic location of the valves. D. The duration of the sound is directly related to the heart rate and rhythm.

A

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a.Dullness across the abdomen b.Flatness in the right upper quadrant c.Hyperresonance in the left upper quadrant d.Tympany in the right and left lower quadrants

A

Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man? a. "Do you need to get up at night to urinate?" b. "Do you experience nocturnal emissions, or 'wet dreams'?" c. "Do you know how to perform a testicular self-examination?" d. "Has anyone ever touched your genitals when you did not want them to?"

A

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: a. The spinous process of C7. b. Usually nonpalpable in most individuals. c. Opposite the interior border of the scapula. d. Located next to the manubrium of the sternum.

A

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a.Palpation b.Inspection c.Percussion d.Auscultation

A

Which statement best describes religion? a. an organized system of beliefs concerning the cause, nature, and purpose, of the universe. b. belief in a divine and superhuman spirit to be obeyed and worshipped c. affiliation with one of the 1200 recognized religions in the United States d. The following of established rituals, especially in conjunction with health-seeking behaviors

A

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage

A

. During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer?

B

10. A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4 C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? a. Alcohol b. Heroin c. Crack cocaine d. Sedatives

B

10. When assessing a patients pain, the nurse knows that an example of visceral pain would be: a. Hip fracture. b. Cholecystitis. c. Second-degree burns. d. Pain after a leg amputation.

B

11. The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance? The person: a. Has a physiologic dependence on a substance. b. Requires an increased amount of the substance to produce the same effect. c. Requires daily use of the substance to function and is unable to stop using it. d. Experiences a syndrome of physiologic symptoms if the substance is not used.

B

12. A mother brings her newborn in for an assessment and asks, Is there something wrong with my baby? His head seems so big. Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

B

12. When assessing the intensity of a patients pain, which question by the nurse is appropriate? a. What makes your pain better or worse? b. How much pain do you have now? c. How does pain limit your activities? d. What does your pain feel like?

B

14. A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect. a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.

B

15. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

B

19. A 10-year-old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 3+/1-4+ with pale coloring b. Tonsils 3+/1-4+ with large white spots c. Tonsils 2+/1-4+ with small plugs of white debris d. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa

B

19. A patient has come in for an examination and states, I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. b. Parotid gland. c. Occipital lymph node. d. Submental lymph node.

B

20. A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, I think that I have the mumps. The nurse would begin by examining the: a. Thyroid gland. b. Parotid gland. c. Cervical lymph nodes. d. Mouth and skin for lesions.

B

24. While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

B

3. The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries? a. 2 b. 4 c. 6 d. 8

B

30. A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? a. "How many teeth did you have at this age?" b. "This is a normal number of teeth for an 18 month old." c. "Normally, by age 2 1/2 years, 16 deciduous teeth are expected." d. "All 20 deciduous teeth are expected to erupt by age 4 years."

B

31. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patients trachea is: a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern.

B

31. When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

B

32. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

B

35. The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty. b. Nonpalpable. c. Large, firm, and fixed to the tissue. d. Rubbery, discrete, and mobile.

B

4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bell palsy. b. Damage to the trigeminal nerve. c. Frostbite with resultant paresthesia to the cheeks. d. Scleroderma.

B

5. In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection

B

6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign

B

6. When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? a. Increased muscle mass b. Decreased liver and kidney functioning c. Decreased blood pressure d. Increased cardiac output

B

9. A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.

B

9. The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? a. Record the results of the assessment, and notify the physician on call. b. State, You are drinking more than is medically safe. I strongly recommend that you quit drinking, and Im willing to help you. c. State, It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter. d. Give the patient information about a local rehabilitation clinic.

B

9. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

B

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism

B

A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? A) Pinworms B) Hemorrhoids C) Colon cancer D) Fecal incontinence

B

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region

B

A 40-year-old black man is in the office for his annual physical. Which statement regarding the prostate-specific antigen (PSA) blood test is true, according to the American Cancer Society? The PSA: A) should be done with this visit. B) should be done at age 45 years. C) should be done at age 50 years. D) is only necessary if there is a family history of prostate cancer.

B

A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.

B

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a."No need to worry. Most men your age develop hernias." b."A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c."A hernia is the result of prenatal growth abnormalities that are just now causing problems." d."I'll have to have your physician explain this to you."

B

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

B

A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if they could be due to the hormone replacement therapy (HRT) she started 3 months ago. The nurse should tell her: A) "Hormone replacement therapy is at such a low dose that side effects are very unusual." B) "Hormone replacement therapy has several side effects, including fluid retention, breast tenderness, and vaginal bleeding." C) "It would be very unusual to have vaginal bleeding with hormone replacement therapy, and I suggest you come in to the clinic immediately to have this evaluated." D) "It sounds as if your dose of estrogen is too high; I think you may need to decrease the amount you are taking and then call back in a week."

B

A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the problem is: A) dysuria. B) stress incontinence. C) hematuria. D) urge incontinence.

B

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

B

A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination. Which of these statements should the nurse include in patient education? "A postmenopausal woman: A) is not at any greater risk for heart disease than a younger woman is." B) should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions." C) has only stopped menstruating; there really are no other significant changes with which she should be concerned." D) is likely to have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle."

B

A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the scrotal skin is thick and edematous. This description is consistent with which of these? a. Varicocele b. Epididymitis c. Spermatocele d. Testicular torsion

B

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n): a. Split S1. b. Atrial gallop. c. Diastolic murmur. d. Summation sound.

B

A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2 b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times.

B

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.

B

A married couple has come to the clinic seeking advice on pregnancy. They have been trying to conceive for 4 months and have not been successful. What should the nurse do first? A) Ascertain whether either of them has been using broad-spectrum antibiotics. B) Explain that couples are considered infertile after 1 year of unprotected intercourse. C) Immediately refer the woman to an expert in pelvic inflammatory disease—the most common cause of infertility. D) Explain that couples are considered infertile after 3 months of engaging in unprotected intercourse and that they will need a referral to a fertility expert.

B

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: a. Assure the mother that these signs are normal symptoms of a cold. b. Recognize that these are serious signs, and contact the physician. c. Ask the mother if the infant has had trouble with feedings. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

B

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.

B

A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: A) "You know that it's important to use condoms for protection, right?" B) "Do you use a condom with each episode of sexual intercourse?" C) "Do you have a sexually transmitted infection?" D) "You are aware of the dangers of unprotected sex, aren't you?"

B

A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: A) "If you are menstruating, please use pads to avoid placing anything into the vagina." B) "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." C) "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you." D) "We would like you to use a mild saline douche before your examination. You may pick this up in our office."

B

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion. b. Hordeolum (stye). c. Dacryocystitis. d. Blepharitis.

B

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate: a. Pneumonia. b. Postnasal drip or sinusitis. c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking.

B

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision. b. Shadow or diminished vision in one quadrant or one half of the visual field. c. Loss of peripheral vision. d. Sudden loss of pupillary constriction and accommodation.

B

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: a. Pain related to lymphatic abnormalities. b. Problems related to arterial insufficiency. c. Problems related to venous insufficiency. d. Pain related to musculoskeletal abnormalities.

B

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as: A. increased bone matrix B. Loss of bone density C. New, weaker bone growth D. Increased phagocytic

B

A patient has hypoactive bowel sounds. What is a possible cause of this finding? a.Diarrhea b.Peritonitis c.Laxative use d.Gastroenteritis

B

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a.Count the patient's respirations. b.Bilaterally percuss the thorax, noting any differences in percussion tones. c.Call for a chest x-ray study, and wait for the results before beginning an assessment. d.Inspect the thorax for any new masses and bleeding associated with respirations.

B

A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to questions the patient's: a. thought process b. judgement c. perception d. intellect

B

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.

B

A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.

B

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a.Obturator test b.Test for Murphy sign c.Iliopsoas muscle test d.Assess for rebound tenderness

B

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: a. Blocking b. Clanging c. Echolalia d. Neologism

B

A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: a. palpate the lump first. b. palpate the unaffected breast first. c. avoid palpating the lump because it could be a cyst, which might rupture. d. palpate the breast with the lump first but plan to palpate the axilla last.

B

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.

B

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing

B

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.

B

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

B

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

B

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: a. Bronchitis. b. Pneumothorax. c. Acute pneumonia. d. Asthmatic attack.

B

A woman has just been diagnosed with HPV, or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _____ cancer. A) uterine B) cervical C) ovarian D) endometrial

B

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.

B

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.

B

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.

B

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A. Long bones tend to shorten with age B. The vertebral column C. Significant loss of subcutaneous fat occurs D. A thickening of the intervertebral disks develops

B

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. A) first sacral B) fourth lumbar C) seventh cervical D) twelfth thoracic

B

An increase in blood volume and workload in the pregnant woman results in the development of: A. orthostatic hypotension. B. a loud and easily heard S3. C. a sustained rise of 30 mm Hg or greater in the systolic blood pressure. D. a venous hum.

B

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes

B

An older patient has been diagnosed with pernicious anemia. This disorder could be r/t what condition? a.Increased gastric acid secretion b.Decreased gastric acid secretion c.Delayed gastrointestinal emptying timed.Increase d gastrointestinal emptying time

B

Arteriosclerosis refers to: a. a deposition of fatty plaques along the intima of the arteries. b. thickening and loss of elasticity of the arterial walls. c a sac formed by dilation in the arterial wall. d a variation from the heart's normal rhythm.

B

As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted.

B

During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." This finding suggests: a. dimpling. b. a retracted nipple. c. nipple inversion. d. deviation in nipple pointing.

B

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: a. "Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease."

B

During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings? a. Deep-vein thrombophlebitis b. Varicose veins c. Lymphedema d. Raynaud phenomenon

B

During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? A) Rectal polyp B) Fecal impaction C) Rectal abscess D) Rectal prolapse

B

During a discussion for a men's health group, the nurse relates that the group with the highest incidence of prostate cancer is: A) Asian Americans. B) African-Americans. C) American Indians. D) Hispanics.

B

During a mental status assessment, which question by the nurse would best assess a person's judgment? a. "Do you feel that you are being watched, followed, or controlled?" b. "Tell me what you plan to do once you are discharged from the hospital." c. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" d. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

B

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: a. Hypopyon. b. Hyphema. c. Corneal abrasion. d. Pterygium.

B

During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d. I can see that you feel sad about this; why dont we talk about something else?

B

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

B

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds? a.1 minute b.5 minutes c.10 minutes d.2 minutes in each quadrant

B

During an abdominal assessment, the nurse would consider which of these findings as normal? a.Presence of a bruit in the femoral area b.Tympanic percussion note in the umbilical region c.Dull percussion note in the left upper quadrant at the midclavicular line d.Palpable spleen between the ninth and eleventh ribs in the left midaxillary line

B

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

B

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: a. Valvular disorder. b. Blood flow turbulence. c. Fluid volume overload. d. Ventricular hypertrophy.

B

During an assessment of a patient's family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a person's near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patient's family members up to five generations back d. Description of the health of a person's children and grandchildren

B

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort

B

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

B

During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be: a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position.

B

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: a. Lymphedema. b. Raynaud disease. c. Deep-vein thrombosis. d. Chronic arterial insufficiency.

B

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? a. Venous stasis b. Lymphedema c. Arteriosclerosis d. Deep-vein thrombosis

B

During an assessment, the nurse uses the "profile sign" to detect: a. Pitting edema. b. Early clubbing. c. Symmetry of the fingers. d. Insufficient capillary refill.

B

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Ask her if her periods have started. b. Assess the girl's weight and body mass index (BMI). c. Ask the girl's mother at what age she started to develop breasts. d. Nothing; this is a normal finding.

B

During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates: a.Constipation. b.Air-filled areas. c.Presence of a tumor. d.Presence of dense organs.

B

During an examination of an aging man, the nurse recognizes that normal changes to expect would be: a. Change in scrotal color. b. Decrease in the size of the penis. c. Enlargement of the testes and scrotum. d. Increase in the number of rugae over the scrotal sac.

B

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: a. Costal angle. b. Sternal angle. c. Xiphoid process. d. Suprasternal notch.

B

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

B

During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: A) stellate. B) small and round. C) as a horizontal irregular slit. D) everted.

B

During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: A) uterine prolapse, graded first degree. B) uterine prolapse, graded second degree. C) uterine prolapse, graded third degree. D) a normal finding.

B

During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."

B

During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding? a. "Breastfed babies tend to be more colicky." b. "Breastfeeding provides the perfect food and antibodies for your baby." c. "Breastfed babies eat more often than infants on formula." d. "Breastfeeding is second nature and every woman can do it."

B

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder

B

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: a. Tactile fremitus. b. Crepitus. c. Friction rub. d. Adventitious sounds.

B

During the examination portion of a patient's visit, she will be in lithotomy position. Which statement below reflects some things that the nurse can do to make this more comfortable for her? A) Ask her to place her hands and arms behind her head. B) Elevate her head and shoulders to maintain eye contact. C) Allow her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table. D) Allow her to keep her buttocks about 6 inches from the edge of the table to prevent her from feeling as if she will fall off.

B

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

B

How would you assess for a pulse deficit? A. Count the radial pulse and then the apical pulse for 1 minute and subtract the apical rate from the peripheral pulse rate, if different. B. Auscultate the apical pulse while simultaneously palpating the radial pulse, counting one after another for 1 minute, and then subtract the radial from the apical, if different. C. Count the apical pulse and then a peripheral pulse for 1 minute and subtract the peripheral pulse rate from the apical rate, if different. D. Auscultate the apical pulse while simultaneously palpating the radial pulse, counting one after another for 1 minute, and then subtract the apical from the radial, if different.

B

If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement. a. nonspecific b. ipsilateral axillary c. contralateral axillary d. inguinal and cervical

B

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? a. Increase in resting heart rate b. Increase in systolic blood pressure c. Decrease in diastolic blood pressure d. Increase in diastolic blood pressure

B

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: a. Bell of the stethoscope at the base with the patient leaning forward. b. Bell of the stethoscope at the apex with the patient in the left lateral position. c. Diaphragm of the stethoscope in the aortic area with the patient sitting. d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.

B

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a. Palpate the artery in the upper one third of the neck. b. Listen with the bell of the stethoscope to assess for bruits. c. Simultaneously palpate both arteries to compare amplitude. d. Instruct the patient to take slow deep breaths during auscultation.

B

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

B

In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is: a. the largest quadrant of the breast. b. the location of most breast tumors. c. where most of the suspensory ligaments attach. d. more prone to injury and calcifications than other locations in the breast.

B

In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patient's reliability. b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious.

B

Mrs. Granowska is 30 years old and pregnant. She comes to the office during the second trimester for a routine follow-up health assessment. As the health care provider, which of the following does not increase in the pregnant woman? A. Blood volume B. Blood pressure C. Stroke volume D. Heart rate

B

Mrs. Schneider comes to the office for a routine health assessment and without complaints. On examination, you note a water-hammer "Corrigan's" pulse. This is associated with: a. hyperkinetic states. b. aortic valve regurgitation. c. conduction disturbance. d. decreased cardiac output.

B

Ms. Kelson is a 26-year-old patient who comes to the clinic for a routine health assessment. On examination, you note a split S2 heart sound. Which of the following is a characteristic of this finding? A. It is only heard with the bell of the stethoscope. B. It is affected by respiration. C. It is auscultated at the second right intercostal space. D. It is more than likely to be pathological.

B

One of the leg's deep veins is the: a. great saphenous. b. popliteal. c. small saphenous. d. tibial.

B

Palatine, pharyngeal, and lingual are specific names for: cervical lymph nodes. tonsils. epitrochlear lymph nodes. axillary lymph nodes.

B

The ability of the heart to contract independently of any signals or stimulation is due to which of the following characteristics? A. Authenticity B. Automaticity C. Autocracy D. Autonomy

B

The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

B

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

B

The component of the conduction system referred to as the pacemaker of the heart is the: a. Atrioventricular (AV) node. b. Sinoatrial (SA) node. c. Bundle of His. d. Bundle branches.

B

The external male genital structures include the: a. Testis. b. Scrotum. c. Epididymis. d. Vas deferens.

B

The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: a. "Puberty usually begins around 15 years of age." b. "The first sign of puberty is an enlargement of the testes." c. "The penis size does not increase until about 16 years of age." d. "The development of pubic hair precedes testicular or penis enlargement."

B

The nurse has just completed an inspection of a nulliparous woman's external genitalia. Which of these would be a description of a finding within normal limits? A) Redness of the labia majora B) Multiple nontender sebaceous cysts C) Discharge that is sticky and yellow-green D) Gaping and slightly shriveled labia majora

B

The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. "Why did you come to the United States?" b. "When did you come to the United States and from what country?" c. "What made you leave your native country?" d. "Are you planning to return to your home?"

B

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

B

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? a. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working. b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. c. An impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line. d. The jugular veins will not be detected during this maneuver.

B

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: A. standing B. flexing the hip C. flexing the knee D. Lying in the supine position

B

The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature? a.Fingertips; they are more sensitive to small changes in temperature. b.Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c.Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d.Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

B

The nurse is assessing the abdomen of a pregnant woman who states she has been having "acid indigestion" all the time. What does the nurse know that esophageal reflux during pregnancy can cause? a.Diarrhea b.Pyrosis c.Dysphagia d.Constipation

B

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a.Abdominal tone is increased. b.Abdominal musculature is thinner. c.Abdominal rigidity with an acute abdominal conditionis more common. d.The older adult with an acute abdominal condition complains more about pain than the younger person.

B

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

B

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposi's sarcoma. c. Angiomas. d. Herpes zoster.

B

The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.

B

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

B

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. "A good time to examine your testicles is just before you take a shower." b. "If you notice an enlarged testicle or a painless lump, call your health care provider." c. "The testicle is egg shaped and movable. It feels firm and has a lumpy consistency." d. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer."

B

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a.When the infant is sleeping b.At the end of the examination c.Before auscultation of the thorax d.Halfway through the examination

B

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.

B

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? a. Excessive swelling of the lymph nodes b. Presence of palpable lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult

B

The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. "Do you believe in God?" b. "Are you a part of any religious or spiritual congregation?" c. "Do you consider yourself to be a religious or spiritual person?" d. "How does your religious faith influence the way you think about your health?"

B

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a.Sound like two pieces of leather being rubbed together b.Are usually high-pitched, gurgling, and irregular sounds c.Are usually loud, high-pitched, rushing, and tinkling sounds d.Originate from the movement of air and fluid through the large intestine

B

The nurse is palpating a female patient's adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurse's most appropriate course of action would be to: A) tell the patient that her examination was normal. B) give her an immediate referral to a gynecologist. C) suggest that she return in a month for a recheck to verify the findings. D) tell the patient that she may have an ovarian cyst that should be evaluated further.

B

The nurse is palpating the prostate gland through the rectum and notices an abnormal finding if which of these is present? A) Palpable central groove B) Tenderness to palpation C) Heart shape D) Elastic and rubbery consistency

B

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a.Tympany b.Dullness c.Resonance d.Hyperresonance

B

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. "Do you wear glasses?" b. "Are you able to dress yourself?" c. "Do you have any thyroid problems?" d. "How many times a day do you have a bowel movement?"

B

The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? A) The rectum is about 8 cm long. B) The anorectal junction cannot be palpated. C) Above the anal canal, the rectum turns anteriorly. D) There are no sensory nerves in the anal canal or rectum.

B

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

B

The nurse is performing the diagnostic positions test. Normal findings would be which of these results? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position

B

The nurse is preparing to auscultate for heart sounds. Which technique is correct? a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest d. Listening for all possible sounds at a time at each specified area

B

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient's family is the best resource for information about the patient's coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient's level of functioning, performing a complete mental status examination is usually necessary.

B

The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a.Explain the procedures in detail to alleviate the child's anxiety. b.Give the child feedback and reassurance during the examination. c.Do not ask the child to remove his or her clothes because children at this age are usually very private. d.Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen.

B

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? a.Examine the tender area first. b.Examine the tender area last. c.Avoid palpating the tender area. d.Palpate the tender area first, and then auscultate for bowel sounds

B

The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a.Usually yields little information. b.Takes time and reveals a surprising amount of information. c.May be somewhat uncomfortable for the expert practitioner. d.Requires a quick glance at the patient's body systems before proceeding with palpation.

B

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? a. Bounding b. Normal c. Weak d. Absent

B

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities

B

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication

B

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a.Slope of the earpieces should point posteriorly (toward the occiput). b.Although the stethoscope does not magnify sound, it does block out extraneous room noise. c.Fit and quality of the stethoscope are not as important as its ability to magnify sound. d.Ideal tubing length should be 22 inches to dampen the distortion of sound.

B

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? a. "Lymph flow is propelled by the contraction of the heart." b. "The flow of lymph is slow, compared with that of the blood." c. "One of the functions of the lymph is to absorb lipids from the biliary tract." d. "Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream."

B

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a."We need to determine the areas of tenderness before using percussion and palpation." b."Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." c."Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." d."Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

B

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.

B

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a.Examiner feel more comfortable and to gain control of the situation. b.Examiner to build rapport and to increase the patient's confidence in him or her. c.Patient understand his or her disease process and treatment modalities. d.Patient identify questions about his or her disease and the potential areas of patient education.

B

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: a. Increased thoracic expansion. b. Decreased mobility of the thorax. c. Decreased anteroposterior diameter. d. Bronchovesicular breath sounds throughout the lungs.

B

The nurse knows that normal splitting of the second heart sound is associated with: a. Expiration. b. Inspiration. c. Exercise state. d. Low resting heart rate.

B

The nurse knows that testing kinesthesia is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

B

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

B

The nurse would use bimanual palpation technique in which situation? a.Palpating the thorax of an infant b.Palpating the kidneys and uterus c.Assessing pulsations and vibrations d.Assessing the presence of tenderness and pain

B

The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotion practices. c. An opportunity to teach the patient medical terms. d. Information necessary for the nurse to diagnose the patient's medical problem.

B

The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the: A) Cowper's gland. B) prostate gland. C) median sulcus. D) bulbourethral gland.

B

The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

B

When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? a. Document the finding. b. Auscultate the site for a bruit. c. Check for calf pain. d. Check capillary refill in the toes.

B

When assessing the scrotum of a male patient, the nurse notices the presence of multiple firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely: a. From urethritis. b. Sebaceous cysts. c. Subcutaneous plaques. d. From an inflammation of the epididymis.

B

When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would: a. Squeeze the glans to check for the presence of discharge. b. Consider this finding as normal, and proceed with the examination. c. Assess the testicles for the presence of masses or painless lumps. d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient has noticed.

B

When performing a physical assessment, the first technique the nurse will always use is: a.Palpation. b.Inspection. c.Percussion. d.Auscultation.

B

When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a.Washing one's hands after removing gloves is not necessary, as long as the gloves are still intact. b.Hands are washed before and after every physical patient encounter. c.Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d.Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

B

When performing a scrotal assessment, the nurse notices that the scrotal contents show a red glow with transillumination. On the basis of this finding the nurse would: a. Assess the patient for the presence of a hernia. b. Suspect the presence of serous fluid in the scrotum. c. Consider this finding normal, and proceed with the examination. d. Refer the patient for evaluation of a mass in the scrotum.

B

When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable. b. Provided consistent information and therefore is reliable. c. Smiled throughout interview and therefore is assumed reliable. d. Would not answer questions concerning stress and therefore is not reliable.

B

Which health belief practice is associated with patients who are of American Indian heritage? a. wearing bangle bracelets to ward off evil spirits b. believing that forces of nature must be kept in natural balance c. using swamp root as a traditional home remedy d. believing in a shaman as a traditional healer.

B

Which of the following best illustrates an abnormality of thought process? a. lability b. blocking c. compulsion d. aphasia

B

Which of the following statements is true regarding the *internal structures* of the breast? The breast is: a. mainly muscle, with very little fibrous tissue. b. composed of fibrous, glandular, and adipose tissue. c. composed mostly of milk ducts, known as lactiferous ducts. d. composed of glandular tissue, which supports the breast by attaching to the chest wall.

B

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures

B

Which of these statements about the sphincters is correct? A) The internal sphincter is under voluntary control. B) The external sphincter is under voluntary control. C) Both sphincters remain slightly relaxed at all times. D) The internal sphincter surrounds the external sphincter.

B

Which of these statements is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase.

B

Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

B

Which statement best illustrates the difference between religion and spirituality? a. religion reflects an individual's reaction to life events whereas spirituality is based on whether the individual attends religious services. b. religion is characterized by identification of a higher being shaping one's destiny, whereas spirituality reflects an individual's perception of one's life having worth or meaning. d. religion is the active interpretation of one's spirituality.

B

Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

B

Which statement is true in regards to pain? a. Nurse's attitudes toward their patients' pain are unrelated to their own experiences with pain b. The cultural background of a patient is important in a nurse's assessment of that patient's pain c. A nurse's area of clinical practice is most likely to determine his or her assessment of a patient's pain d. A nurse's years of clinical experience and current position are a strong indicator of his or her response to patient pain.

B

Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? a. Congruence mechanism b. Heritage consistency c. Behavior theory d. Socialization experience

B

While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings? a. S3 is indicative of heart disease in children. b. These findings can all be normal in a child. c. These findings are indicative of congenital problems. d. The venous hum most likely indicates an aneurysm.

B

While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a.Electrocardiogram b.Bell of the stethoscope c.Diaphragm of the stethoscope d.Palpation with the nurse's palm of the hand

B

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. What does the nurse suspect? a.Pulsations of the renal arteries b.Normal abdominal aortic pulsations c.Pulsations of the inferior vena cava d.Increased peristalsis from a bowel obstruction

B

While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should: a. palpate over the Montgomery's glands, checking for drainage. b. consider these normal findings and proceed with the examination. c. ask extensive history questions regarding the woman's breast asymmetry. d. continue with examination and then refer the patient for further evaluation of the Montgomery's glands.

B

With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient "blow out" the light on the penlight? a.Infant b.Preschool child c.School-age child d.Adolescent

B

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. "Please stay during the interview; you can answer for her if she does not know the answer." b. "It would help to interview the three of you together." c. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?" d. "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?"

D

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patient's biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patient's past and current health

D

The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities.

D

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a.Performs the examination from the left side of the bed. b.Examines tender or painful areas first to help relieve the patient's anxiety. c.Follows the same examination sequence, regardless of the patient's age or condition. d.Organizes the assessment to ensure that the patient does not change positions too often.

D

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a.Is often used to direct light onto the sinuses. b.Uses a short, broad speculum to help visualize the ear. c.Is used to examine the structures of the internal ear. d.Directs light into the ear canal and onto the tympanic membrane.

D

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.

D

The nurse is providing patient teaching about an erectile dysfunction drug. One of the drug's potential side effects is prolonged, painful erection of the penis without sexual stimulation, which is known as: a. Orchitis. b. Stricture. c. Phimosis. d. Priapism.

D

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick? a. The atria contract during systole and attempt to push against closed valves. b. Contraction of the atria at the beginning of diastole can be felt as a palpitation. c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

D

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

D

The nurse is reviewing information on lactose intolerance and learned that in some racial groups lactase activity (ability to digest and absorb lactose) is high at birth but declines to low levels by adulthood. Which ethnic group has the highest potential for lactose-intolerance symptoms in adulthood? a.Asians b.African Americans c.White Americans d.American Indians

D

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. "Your breast milk is present immediately after delivery of the baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrition as breast milk does." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

D

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

D

The nurse knows that a common assessment finding in a boy younger than 2 years old is: a. Inflamed and tender spermatic cord. b. Presence of a hernia in the scrotum. c. Penis that looks large in relation to the scrotum. d. Presence of a hydrocele, or fluid in the scrotum.

D

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

D

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

D

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.

D

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a.Percuss and palpate in the lumbar region b.Inspect and palpate in theepigastric region c.Auscultate and percuss in the inguinal region d.Percuss and palpate the midline area above the suprapubic bone

D

The term culturally competent implies that the nurse a. is prepared in nursing b. possesses knowledge of the traditions of diverse peoples c. applies underlying knowledge to providing nursing care. d. understands the cultural context of the patient's situation.

D

The top of the heart, as it is positioned in the chest, is anatomically identified as the: A. crux. B. apex. C. integrant. D. base.

D

What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment

D

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulses: a. Alternans. b. Bisferiens. c. Bigeminus. d. Paradoxus.

D

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: a. Presence of phobias b. General intelligence c. Presence of irrational thinking patterns d. Sensory-perceptive abilities

D

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5

D

When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that: a. Are often associated with venous disease. b. Occur in the presence of lymphadenopathy. c. In the femoral arteries are caused by hypermetabolic states. d. Occur with turbulent blood flow, indicating partial occlusion.

D

When examining a 16-year-old male teenager, the nurse should: a.Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b.Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c.Talk to him the same manner as one would talk to a younger child because a teen's level of understanding may not match his or her speech. d.Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.

D

When examining an infant, the nurse should examine which area first? a.Ear b.Nose c.Throat d.Abdomen

D

When examining an older adult, the nurse should use which technique? a.Avoid touching the patient too much. b.Attempt to perform the entire physical examination during one visit. c.Speak loudly and slowly because most aging adults have hearing deficits. d.Arrange the sequence of the examination to allow as few position changes as possible.

D

When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

D

When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: a. Carcinoma. b. Syphilitic chancres. c. Genital herpes. d. Genital warts.

D

When performing a genitourinary assessment on a 16-year-old male adolescent, the nurse notices a swelling in the scrotum that increases with increased intra-abdominal pressure and decreases when he is lying down. The patient complains of pain when straining. The nurse knows that this description is most consistent with a(n) ______ hernia. a. Femoral b. Incisional c. Direct inguinal d. Indirect inguinal

D

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patient's abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

D

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.

D

When testing stool for occult blood, the nurse is aware that a false-positive result may occur with: A) absent bile pigment. B) increased fat content. C) increased ingestion of iron medication. D) a large amount of red meat within the last 3 days.

D

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

D

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique? a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it. b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations. c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

D

When the nurse is conducting sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview? a. "Do you use condoms?" b. "You don't masturbate, do you?" c. "Have you had sex in the last 6 months?" d. "Often adolescents your age have questions about sexual activity."

D

When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurse's most appropriate action or response is to: a. Ask the patient if he would like someone else to examine him. b. Continue with the examination as though nothing has happened. c. Stop the examination, leave the room while stating that the examination will resume at a later time. d. Reassure the patient that this is a normal response and continue with the examination.

D

When the nurse is performing a genital examination on a male patient, which action is correct? a. Auscultating for the presence of a bruit over the scrotum b. Palpating for the vertical chain of lymph nodes along the groin, inferior to the inguinal ligament c. Palpating the inguinal canal only if a bulge is present in the inguinal region during inspection d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side

D

Which category is appropriate in a cultural assessment? a. family history b. chief complaint c. past medical history d. health-related beliefs.

D

Which of the following guidelines may be used to identify which heart sound is S1? A. S1 coincides with the A wave of the jugular venous pulse wave. B. S1 is louder than S2 at the base of the heart. C. S1 coincides with the Q wave of the QRS ECG complex. D. S1 coincides with the carotid artery pulse.

D

Which of the following statements is true regarding murmurs? A. A murmur graded 5 can be heard with the stethoscope that is lifted just off the chest wall. B. Low-pitched murmurs are less pathological than high-pitched murmurs. C. All systolic murmurs are generally considered functional or innocent. D. Diastolic murmurs always indicate heart disease.

D

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply.) a.Test for fluid wave b.Test for the Murphy sign c.Test for the Blumberg sign d.Test for shifting dullness e.Perform the iliopsoas muscle test

C, E

A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "This is a normal change that occurs as women get older. It is due to the increased levels of progesterone during the aging process." c. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help to prevent the changes in elasticity and size."

C

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.

C

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying

C

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? a. Obtaining a detailed health history of the patient's allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

C

A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.

C

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. "Signs of decreased hematocrit related to anemia." b. "Due to the destruction of melanin in your skin from exposure to the sun." c. "Clusters of melanocytes that appear after extensive sun exposure." d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

C

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor.

C

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

C

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."

C

A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: A) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test

C

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

C

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

C

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? a. Tell the mother that breast development is usually fairly symmetric and she should be examined right away. b. Tell the mother that she should bring her daughter in right away because breast cancer is fairly common in preadolescent girls. c. Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development. d. Tell the mother that it is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue.

C

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

C

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

C

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing

C

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion

C

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: a. May display some disruption in thought content. b. Will state, "I am so relieved to be out of intensive care." c. Will be oriented to place and person, but the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness.

C

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.

C

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication

C

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment

C

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

C

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar

C

A patient repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." The nurse will note on his chart that he is using or experiencing: a. Blocking b. Neologism c. Circumlocution d. Circumstantiality

C

A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? a. "Have you had any weight changes?" b. "Are you having any thoughts of suicide?" c. "How long have you been feeling this way?" d. "Are you having feelings of worthlessness?"

C

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures

C

A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for about the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are most indicative of: A) excessive fat caused by malabsorption. B) increased iron intake resulting from a change in diet. C) occult blood resulting from gastrointestinal bleeding. D) absent bile pigment from liver problems.

C

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

C

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

C

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.

C

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." b. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." c. "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." d. "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate."

C

A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed: A) a change in your urination patterns?" B) any excessive vaginal bleeding?" C) any unusual vaginal discharge or itching?" D) any changes in your desire for intercourse?"

C

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: a. memory, attention, thought content, and perceptions b. language, orientation, attention, and abstract reasoning c. appearance, behavior, cognition, and thought process d. mood, affect, consciousness, and orientation

C

An accessory glandular structure for the male genital organs is the: a. Testis. b. Scrotum. c. Prostate. d. Vas deferens.

C

An aneurysm is: a. a fatty plaque deposited in the intima of the arteries. b. a thickening and loss of elasticity of the arterial walls. c. a sac formed by dilation in the arterial wall. d. a variation from the heart's normal rhythm.

C

An older adult: a. experiences a 10-point decrease in intelligence b. has diminished recent and remote memory recall c. has a slower response time d. has difficulty with problem solving

C

As individuals age, the arterial walls become stiffer and less compliant. Which of the following can be attributed to this age-related change? A. Decreased cardiac output B. Decreased pulse pressure C. Rising systolic blood pressure D. Decreasing diastolic blood pressure

C

Atherosclerosis is defined as: a. a swooshing sound heard through a stethoscope when an artery is partially occluded. b. a thickening and loss of elasticity of the arterial walls. c. plaques of fatty deposits forming in the intima of the arteries. d. a sac formed by dilation in the arterial wall.

C

Displacement of the apical impulse down and toward the left, with an increased size that occupies more than one interspace, occurs with: A. pulmonary emphysema. B. left ventricular hypertrophy without dilatation. C. left ventricular dilatation. D. left atrial dilatation.

C

During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. This finding is suggestive of: A) an ovarian cyst. B) endometriosis. C) ovarian cancer. D) an ectopic pregnancy.

C

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: a. Heard at the onset of atrial diastole. b. Usually a normal finding in the older adult. c. Heard at the end of ventricular diastole. d. Heard best over the second left intercostal space with the individual sitting upright.

C

During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. "The best time to examine your breasts is during ovulation." b. "Examine your breasts every month on the same day of the month." c. "Examine your breasts shortly after your menstrual period each month." d. "The best time to examine your breasts is immediately before menstruation."

C

During a genital examination, the nurse notices that a male patient has clusters of small vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions are: a. Peyronie disease. b. Genital warts. c. Genital herpes. d. Syphilitic cancer.

C

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition? a.Appendicitis b.Gastric ulcer c.Duodenal ulcer d.Cholecystitis

C

During a history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Contact the physician immediately to report the discharge. b. Ask her if she is possibly pregnant. c. Ask her some additional questions about the medications she is taking. d. Immediately obtain a sample for culture and sensitivity testing.

C

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.

C

During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine? a. Is the rash raised and red? b. Does it appear to be cyclic? c. Where did it first appear-on the nipple, the areola, or the surrounding skin? d. What was she doing when she first noticed the rash, and do her actions make it worse?

C

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.

C

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure?a.Spleen b.Sigmoid c.Appendix d.Gallbladder

C

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

C

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

C

During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked? A) A jerking of the legs B) Flexion of the knees C) A quick contraction of the sphincter D) Relaxation of the external sphincter

C

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Adventitious sounds and limited chest expansion. b. Increased tactile fremitus and dull percussion tones. c. Muffled voice sounds and symmetric tactile fremitus. d. Absent voice sounds and hyperresonant percussion tones.

C

During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a.Constipation b.Abdominal tumor c.Umbilical hernia d.Intra-abdominal bleeding

C

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? a. Assessing the eye for a possible foreign body b. Documenting the finding as ptosis c. Assessing for other signs of ectropion d. Contacting the prescriber; these are signs of basal cell carcinoma

C

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Breasts should always be symmetric. b. This finding is probably due to breastfeeding and is nothing to worry about. c. This finding is not unusual, but the nurse should verify that this change is not new. d. This finding is very unusual and means she may have an inflammation or growth.

C

During an examination of an aging man, the nurse recognizes that normal changes to expect would be: a. Enlarged scrotal sac. b. Increased pubic hair. c. Decreased penis size. d. Increased rugae over the scrotum

C

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.

C

During an examination, the nurse can assess mental status by which activity? a. Examining the patient's electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patient's response to a specific set of questions

C

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? a. "My stomach hurts. Hurts, spurts, burts." b. "Kiss, wood, reading, ducks, onto, maybe." c. "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." d. "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands."

C

During an examination, the nurse notices that a male patient has a red, round, superficial ulcer with a yellowish serous discharge on his penis. On palpation, the nurse finds a nontender base that feels like a small button between the thumb and fingers. At this point the nurse suspects that this patient has: a. Genital warts. b. Herpes infection. c. Syphilitic chancre. d. Carcinoma lesion.

C

During an external genitalia examination of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware of any problems in that area. The nurse recognizes that these lesions may be: A) syphilitic chancre. B) herpes simplex virus type 2 (herpes genitalis). C) human papillomavirus (HPV), or genital warts. D) pediculosis pubis (crab lice).

C

During an internal examination of a woman's genitalia, the nurse will use which technique for proper insertion of the speculum? A) Instruct the woman to bear down, open the speculum blades, and apply in a swift, upward movement. B) Insert the blades of the speculum on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. Ask the woman to bear down after the speculum is inserted. C) Instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman's back. D) Lock the blades open by turning the thumbscrew. Once the blades are open, apply pressure to the introitus and insert the blades at a 45-degree angle downward to bring the cervix into view.

C

During an interview, the nurse would expect that most of the interview will take place at what distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance

C

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Airway obstruction b. Emphysema c. Pulmonary consolidation d. Asthma

C

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate? a."Your atrial dysrhythmias are under control." b."You have pitting edema and mild varicosities." c."Your pulse is 80 beats per minute, which is within the normal range." d."I'm using my stethoscope to listen for any crackles, wheezes, or rubs."

C

During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

C

During the interview with a female patient, the nurse gathers data that indicate that the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? A) "I have noticed that my muscles ache at night when I go to bed." B) "I will be very happy when I can stop worrying about having a period." C) "I have been noticing that I sweat a lot more than I used to, especially at night." D) "I have only been pregnant twice, but both times I had breast tenderness as my first symptom."

C

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. A unilateral inversion of a nipple is always a serious sign. c. It should be determined whether the inversion is a recent change. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.

C

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: a. Right ventricular hypertrophy. b. Increased volume and size of the heart as a result of pregnancy. c. Displacement of the heart from elevation of the diaphragm. d. Increased blood flow through the internal mammary artery.

C

In a patient who has anisocoria, the nurse would expect to observe: a. Dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens.

C

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a. Family history, hypertension, stress, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol

C

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Ignore it; it is not unusual for men to have benign breast enlargement. c. Explain that this condition may be the result of hormonal changes and recommend that he see his physician. d. Tell him that gynecomastia in men is usually associated with prostate enlargement and recommend that he be screened thoroughly.

C

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal nodes b. Pectoral, lateral, anterior, and sternal nodes c. Central, lateral, pectoral, and subscapular nodes d. Lateral, pectoral, axillary, and suprascapular nodes

C

In pulsus bigeminus: there is a deficiency of oxygenated arterial blood to a body part. the rhythm is regular, but the force of the pulse varies with alternating beats. the rhythm is coupled-every other beat is premature. beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration.

C

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. "This has been a difficult year for you." b. "I don't know how anyone could handle that much stress in 1 year!" c. "What did you do to cope with the loss of both your husband and mother?" d. "That is a lot of stress; now let's go on to the next section of your history."

C

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

C

Mr. Duguay is a 68-year-old man who comes to the clinic for a routine health assessment. In the older adult: a. the peripheral vessels become less rigid. b. the number of lymph nodes increases. c. the lymphatic tissue decreases. d. the intramuscular calf veins shrink.

C

Mrs. Lukianchuk is a 65-year-old patient who presents to the ambulatory health centre with a complaint of bilateral foot pain. On examination, you note delayed venous filling. This occurs with: a. incompetent valves. b. anemia. c. arterial insufficiency. d. aortic valve stenosis.

C

Mrs. Marcos is a 27-year-old pregnant woman who goes to the clinic for general prenatal care. On examination, which of the following cardiac assessment findings are commonly associated with the pregnant woman? A. An apical impulse that is displaced higher and medially B. A soft S4 C. An exaggerated splitting of S1 D. A loud, diastolic murmur that disappears shortly after delivery

C

The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

C

The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone.

C

The cervical nodes drain the: a. upper arm and breast. b. external genitalia. c. head and neck. d. hand and lower arm.

C

The changes normally associated with menopause occur generally because the cells in the reproductive tract are: A) aging. B) becoming fibrous. C) estrogen dependent. D) able to respond to estrogen.

C

The major factor contributing to the need for cultural care in nursing is: a. an increasing birth rate b. limited access to health care service c. demographic change d. a decreasing rate of immigration

C

The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a.Wear protective eye wear at all times. b.Wear gloves during any and all contact with patients. c.Wash hands before and after contact with each patient. d.Clean the stethoscope with an alcohol swab between patients.

C

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma

C

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individuals condition, and compare actual outcomes with expected outcomes. d. Interpret data, and then identify clusters of cues and make inferences.

C

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: a. the shape of the lump. b. the lump's consistency. c. the size of the lump. d. whether the lump is solitary or multiple.

C

The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.

C

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

C

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: a. Check color vision annually until the age of 18 years. b. Ask the child to identify the color of his or her clothing. c. Test for color vision once between the ages of 4 and 8 years. d. Begin color vision screening at the child's 2-year checkup.

C

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

C

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. a. Normal b. Absent c. Bounding d. Weak, thready

C

The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the chest d. Lightly holding the bell of the stethoscope against the chest to avoid friction

C

The nurse is aware of which statement to be true regarding the incidence of testicular cancer? a. Testicular cancer is the most common cancer in men aged 30 to 50 years. b. The early symptoms of testicular cancer are pain and induration. c. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer. d. The cure rate for testicular cancer is low.

C

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

C

The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. The woman needs to do BSE only bimonthly unless she has fibrocystic breast tissue. c. The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, the woman should not perform a BSE until her baby is born.

C

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? a. "I sleep like a baby." b. "I have no health problems." c. "I never did too good in school." d. "I am not currently taking any medications."

C

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? a. "Is easily palpable; pounds under the fingertips." b. "Has greater than normal force, then suddenly collapses." c. "Is hard to palpate, may fade in and out, and is easily obliterated by pressure." d. "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

C

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? a. Percussion is a useful tool for outlining the heart's borders. b. Percussion is easier in patients who are obese. c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border. d. Only expert health care providers should attempt percussion of the heart.

C

The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a.Washing hands, and contacting the physician b.Continuing to examine the ulceration, and then washing hands c.Washing hands, putting on gloves, and continuing with the examination of the ulceration d.Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration

C

The nurse is examining only the rectal area of a woman and should place the woman in what position? A) Lithotomy position B) Prone position C) Left lateral decubitus position D) Bending over the table while standing

C

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities

C

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: a. Increased cardiac output. b. Another MI. c. Inflammation of the precordium. d. Ventricular hypertrophy resulting from muscle damage.

C

The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) ______ hernia. a. Scrotal b. Femoral c. Direct inguinal d. Indirect inguinal

C

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status assessment diagnoses specific psychiatric disorders. b. Mental disorders occur in response to everyday life stressors. c. Mental status functioning is inferred through the assessment of an individual's behaviors. d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

C

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

C

The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. The questions asked are identical for all ages. b. The interviewer will start incorporating different questions for patients 70 years of age and older. c. Questions that are reflective of the normal effects of aging are added. d. At this age, a review of systems is not necessary—the focus should be on current problems..

C

The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His medical history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this situation? a. Enlarged, warm, and tender nodes b. Lymphadenopathy of the cervical nodes c. Palpable firm, small, shotty, mobile, and nontender lymph nodes d. Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue

C

The nurse is performing an abdominal assessment. What types of percussion notes can be heard during abdominal assessment? a.Flatness, resonance, and dullness b.Resonance, dullness, and tympany c.Tympany, hyperresonance, and dullness d.Resonance, hyperresonance, and flatness

C

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

C

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.

C

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? a. "Please count backward from 100 by seven." b. "I will name three items and ask you to repeat them in a few minutes." c. "Please point to articles in the room and parts of the body as I name them." d. "What would you do if you found a stamped, addressed envelope on the sidewalk?"

C

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic.

C

The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in African-American women in the United States? a. Breast cancer is not a threat to African-American women. b. African-American women have a lower incidence of regional or distant breast cancer than white women. c. African-American women are more likely to die of breast cancer at any age. d. Breast cancer incidence in African-American women is higher than that of white women after age 45.

C

The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct? A) Bimanual, speculum, rectovaginal B) Speculum, rectovaginal, bimanual C) Speculum, bimanual, rectovaginal D) Rectovaginal, bimanual, speculum

C

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

C

The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a.The thorax, abdomen, and genitalia are examined before the head. b.Talking about the equipment being used is avoided because doing so may increase the child's anxiety. c.The nurse should keep in mind that a child at this age will have a sense of modesty. d.The child is asked to undress from the waist up.

C

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue. a.Turgor b.Texture c.Density d.Consistency

C

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

C

The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? a. "BSE is more important than ever for you because you have never had any children." b. "BSE is so important because one out of nine women will develop breast cancer in her lifetime." c. "BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations." d. "BSE will save your life because you are likely to find a cancerous lump between mammograms."

C

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

C

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinician's experience. d. The patients own preferences are not important with EBP.

C

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a.A bruit is absent. b.Femoral pulses are increased. c.A pulsating mass is usually present. d.Most are located below the umbilicus.

C

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. a. Ulnar b. Radial c. Brachial d. Deep palmar

C

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are: a. Musical in quality. b. Usually caused by a pathologic disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration.

C

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile remits: a. "Is caused by moisture in the alveoli." b. "Indicates that air is present in the subcutaneous tissues." c. "Is caused by sounds generated from the larynx." d. "Reflects the blood flow through the pulmonary arteries."

C

The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness. d. Fractured bones.

C

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

C

The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a.Ask the patient to take deep breaths to relax the abdominal musculature. b.Consider this finding as normal, and proceed with the abdominal assessment. c.Increase the amount of strength used when attempting to percuss over the abdomen. d.Decrease the amount of strength used when attempting to percuss over the abdomen.

C

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a.Auscultate over the area with a fetoscope. b.Use a goniometer to measure the pulsations. c.Use a Doppler device to check for pulsations over the area. d.Check for the presence of pulsations with a stethoscope.

C

The nurse knows that auscultation of fine crackles would most likely be noticed in: a. A healthy 5-year-old child. b. A pregnant woman. c. The immediate newborn period. d. Association with a pneumothorax.

C

The nurse notices that a patient has had a black, tarry stool. What should the nurse recognize may cause this finding? a.Gallbladder disease b.Overuse of laxatives c.Gastrointestinal bleeding d.Localized bleeding around the anus

C

The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: A) occult bleeding. B) absent bile pigment. C) increased fat content. D) ingestion of bismuth preparations.

C

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.

C

The nurse recognizes that the concept of prevention in describing health is essential because: a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care practitioners.

C

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.

C

The physician comments that a patient has abdominalborborygmi. What is the best description of this term? a.Hypoactive bowel sounds b.A peritoneal friction rub c.Loud gurgling bowel sounds d.Loud continual humming bowel sounds

C

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus

C

When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: a. continue to nurse on both sides to encourage milk flow. b. discontinue nursing immediately to allow for healing. c. temporarily discontinue nursing on affected breast and manually express milk and discard it. d. temporarily discontinue nursing on affected breast but can manually express milk and give it to the baby.

C

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis. b. Presence of conjunctivitis over the iris. c. Presence of shadows, which may indicate glaucoma. d. Scattered light reflex, which may be indicative of cataracts.

C

When assessing a newborn infant who is 5 minutes old, the nurse knows that which of these statements would be true? a. The left ventricle is larger and weighs more than the right ventricle. b. The circulation of a newborn is identical to that of an adult. c. Blood can flow into the left side of the heart through an opening in the atrial septum. d. The foramen ovale closes just minutes before birth, and the ductus arteriosus closes immediately after.

C

When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose

C

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Crepitus palpated at the costochondral junctions b. No diaphragmatic excursion as a result of a child's decreased inspiratory volume c. Presence of bronchovesicular breath sounds in the peripheral lung fields d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

C

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: a. Normally auscultated over the trachea. b. Bronchial breath sounds and normal in that location. c. Vesicular breath sounds and normal in that location. d. Bronchovesicular breath sounds and normal in that location.

C

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body.

C

When listening to heart sounds, the nurse knows that S1: a. Is louder than the S2 at the base of the heart. b. Indicates the beginning of diastole. c. Coincides with the carotid artery pulse. d. Is caused by the closure of the semilunar valves.

C

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: a. Mitral and tricuspid. b. Tricuspid and aortic. c. Aortic and pulmonic. d. Mitral and pulmonic.

C

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: a. Check for the presence of claudication. b. Refer the individual for further evaluation. c. Consider this finding as normal, and proceed with the peripheral vascular evaluation. d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

C

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.

C

When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse's interpretation of these results should be which of these? A) These findings are all within normal limits. B) The cervical consistency should be soft and velvety—not firm. C) The cervix should move when palpated; an immobile cervix may indicate malignancy. D) Pain may occur during palpation of the cervix.

C

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

C

When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care

C

When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal? a. Nontender subcutaneous plaques b. Scrotal area that is dry, scaly, and nodular c. Testes that feel oval and movable and are slightly sensitive to compression d. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the testes

C

When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm

C

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Regular "lub, dub" pattern c. Swishing, whooshing sound d. Steady, even, flowing sound

C

Which culture would describe illness as hot and cold imbalance? a. Asian-American heritage b. African-American heritage c. Hispanic-American heritage d. American Indian heritage

C

Which direction would you give a patient to assist you with palpating the femoral pulse? a. "Push your leg down against the examining table." b. "Relax your leg and turn your foot and knee inward." c. "Bend your knee outward like a frog." d. "Straighten your leg and point your toe."

C

Which of the following cardiac alterations occurs in the pregnant woman? A. An increased stroke volume with decreased cardiac output B. An increased heart rate and increased blood pressure C. An increase in cardiac volume and a decrease in blood pressure D. An increase in cardiac output and blood pressure

C

Which of the following is true regarding the jugular venous pulse wave? A. It is located in the groove between the trachea and the sternomastoid muscle. B. Its timing closely coincides with ventricular systole. C. It results from a backwash of pressure from events that occur in the heart. D. It is characterized by a rapid upstroke and a gradual downstroke with a dicrotic notch.

C

Which of the following statements about mental status testing of children is correct? a. the results of the Denver II screening test are valid for white, middle-class children only b. the behavioral checklist is useful to assess children who are 3 to 5 years old c. abnormal findings are usually related to not achieving an expected developmental milestone d. input from parents and caretakers is discouraged when assessing psychosocial developement

C

Which of the following statements regarding language barriers and health care is true? a. English proficiency is associated with a lower quality of care. b. Patients with language barriers have a decreased risk for nonadherence to medication regimens. c. Standards have been identified that are important to eliminate health disparities. d. LEP is associated with a higher quality of care.

C

Which of the following symptoms is greatly influenced by a person's cultural heritage? a. food intolerance b. hearing loss c. pain d. breast lump

C

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? a. S3 when sitting up b. Persistent tachycardia above 150 beats per minute c. Murmur at the second left intercostal space when supine d. Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line

C

Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The aortic valve closes slightly before the tricuspid valve. b. The pulmonic valve closes slightly before the aortic valve. c. The tricuspid valve closes slightly later than the mitral valve. d. Both the tricuspid and pulmonic valves close at the same time.

C

Which of these statements is true regarding the use of Standard Precautions in the health care setting? a.Standard Precautions apply to all body fluids, including sweat. b.Use alcohol-based hand rub if hands are visibly dirty. c.Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. d.Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

C

Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm.

C

Which statement best describes ethnocentrism? a. the government description of various cultures b. a central belief that accepts all cultures as one's own c. the tendency to view your own way of life as the most desirable. d. the tendency to impose your beliefs, values, and patterns of behavior on an individual from another culture.

C

Which statement best reflects the magicoreligious causation of illness? a. each being is but part of a larger structure in the world of nature as it relates to health and illness b. causality relationships exist, leading to expression of illness c. belief in the struggle between good and evil is reflected in the regulation of health and illness d. illness occurs as a result of disturbances between hot and cold reactions.

C

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? A) "Now it is time to talk about your sexual history. When did you first have intercourse?" B) "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" C) "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" D) "Most women your age have had more than one sexual partner. How many would you say you have had?"

C

While assessing a hospitalized, bedridden patient, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicates which of the following? A) Occult blood B) Inflammation C) Absent bile pigment D) Ingestion of iron preparations

C

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? a. Talk with the patient about his intake of caffeine. b. Perform an electrocardiogram after the examination. c. No further response is needed because sinus arrhythmia can occur normally. d. Refer the patient to a cardiologist for further testing.

C

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: a. dimpling. b. retraction. c. peau d'orange. d. benign breast disease.

C

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

C

You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional respectful demeanor b. allowing for additional time to complete the process c. providing the patient with a paper and pencil so he or she can write down the answers to the questions you are going to ask d. seeing is there are any family members present who may assist with the interview process.

C

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A. symmetric joint involvement B. asymmetric joint involvement C. pain with motion of affected joints D. affected joints are swollen with hard, bony protuberances E. affected joint may have heat, redness, and swelling

B C D

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for myocardial infarction (MI)? Select all that apply. a. Ethnicity b. Abnormal lipids c. Smoking d. Gender e. Hypertension f. Diabetes g. Family history

B C E F

The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass's characteristics would suggest the presence of an ovarian cyst? Select all that apply. A) Heavy and solid B) Mobile and fluctuant C) Mobile and solid D) Fixed E) Smooth and round F) Poorly defined

B E

1. The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply. a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes

B, D, F

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. a. Patient may experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in the late stages. c. Immediate treatment is needed. d. Vision loss begins with peripheral vision. e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision. f. Virtually no symptoms are exhibited.

B, D, F

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

B, E

11. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." What is the best response by the nurse? a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

D

12. A 72-year-old patient has a history of hypertension and chronic lung disease. Which is an important question for the nurse to include in this patient's health history? a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

D

15. A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension b. Cluster headaches. c. Tension headaches. d. Migraine headaches.

D

16. A 19-year-old college student is brought to the emergency department with a severe headache he describes as, Like nothing I've ever had before. His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

D

18. A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

D

2. A mother brings her 2-month-old daughter in for an examination and says, My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong? The nurses best response would be: a. Perhaps that could be a result of your dietary intake during pregnancy. b. Your baby may have craniosynostosis, a disease of the sutures of the brain. c. That soft spot may be an indication of cretinism or congenital hypothyroidism. d. That soft spot is normal, and actually allows for growth of the brain during the first year of your babys life.

D

25. A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started to bleed. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy."

D

28. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a. Cushing syndrome. b. Parkinson disease. c. Bell palsy. d. Experienced a cerebrovascular accident (CVA) or stroke.

D

28. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of what disease or disorder? a. Measles b. Leukemia c. A carcinoma d. Acquired immunodeficiency syndrome (AIDS)

D

29. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

D

3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

D

32. When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute rhinitis c. Acute sinusitis d. Allergic rhinitis

D

34. The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. A painful vesicle inside the cheek for 2 days b. The presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. An ulceration on the side of the tongue with rolled edges

D

38. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate? a. Nasal polyps b. Frontal sinusitis c. Posterior epistaxis d. Maxillary sinusitis

D

39. A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. What is the likely reason for this? a. Inappropriate use of nasal sprays b. A problem with the patient's coagulation system c. Increased susceptibility to colds and nasal irritation d. Increased vascularity in the upper respiratory tract as a result of the pregnancy

D

4. What is the tissue that connects the tongue to the floor of the mouth called? a. Uvula b. Palate c. Papillae d. Frenulum

D

5. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, How many drinks a day is safe for my baby? The nurses best response is: a. You should limit your drinking to once or twice a week. b. Its okay to have up to two glasses of wine a day. c. As long as you avoid getting drunk, you should be safe. d. No amount of alcohol has been determined to be safe during pregnancy.

D

6. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." What is the best response by the nurse? a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3-month-old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

D

7. During an assessment, the nurse asks a female patient, How many alcoholic drinks do you have a week? Which answer by the patient would indicate at-risk drinking? a. I may have one or two drinks a week. b. I usually have three or four drinks a week. c. Ill have a glass or two of wine every now and then. d. I have seven or eight drinks a week, but I never get drunk.

D

A 13-year-old girl is visiting the clinic for a sports physical. The nurse should remember to include which of these tests in the examination? A) Test for occult blood B) The Valsalva maneuver C) Internal palpation of the anus D) Inspection of the perianal area

D

A 15-year-old boy is seen in the clinic for complaints of "dull pain and pulling" in the scrotal area. On examination, the nurse palpates a soft, irregular mass posterior to and above the testis on the left. This mass collapses when the patient is supine and refills when he is upright. This description is consistent with: a. Epididymitis. b. Spermatocele. c. Testicular torsion. d. Varicocele

D

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: a. She probably does not have any problems. b. She is only trying to shock people and that her dress should be ignored. c. She has a manic syndrome because of her abnormal dress and grooming. d. More information should be gathered to decide whether her dress is appropriate.

D

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's: a. Affect and mood b. Memory and affect c. Language abilities d. Level of consciousness and cognitive abilities

D

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a.The spleen can be enlarged as a result of trauma. b.The spleen is normally felt on routine palpation. c.If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d.An enlarged spleen should not be palpated because it can easily rupture.

D

A 22-year-old woman has been considering using oral contraceptives. As a part of her history, the nurse should ask: A) "Do you have a history of heart murmurs?" B) "Will you be in a monogamous relationship?" C) "Have you thought this choice through carefully?" D) "If you smoke, how many cigarettes do you smoke per day?"

D

A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. There is also inguinal lymphadenopathy present. The most likely cause of these lesions is: A) pediculosis pubis. B) contact dermatitis. C) human papillomavirus. D) herpes simplex virus type 2.

D

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? a. "How do you usually feel? Is this normal behavior for you?" b. "I am going to say four words. In a few minutes, I will ask you to recall them." c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" d. "Pick up the pencil in your left hand, move it to your right hand, and place it on the table."

D

A 25-year-old woman comes to the emergency department with a sudden fever of 101° F and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: A) endometriosis. B) uterine fibroids. C) ectopic pregnancy. D) pelvic inflammatory disease.

D

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? a. "How are things going with the trial?" b. "How are things going with your job?" c. "Tell me about your recent engagement!" d. "Are you having any disturbing dreams?"

D

A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? a. "How does your family react to your pain?" b. "The pain must be terrible. You probably pinched a nerve." c. "I've had back pain myself, and it can be excruciating." d. "How would you say the pain affects your ability to do your daily activities?"

D

A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with: a. Heart failure. b. Aortic stenosis. c. Pulmonary edema. d. Mitral regurgitation.

D

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

D

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? A) "It depends. Do you smoke?" B) "This will need to be done annually until you are 65." C) "If you have 2 consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have 3 consecutive normal Pap tests, then you may be screened every 2 to 3 years."

D

A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child's birth weight b. Age at which he crawled c. Whether the child has had the measles d. Child's reactions to previous hospitalizations

D

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

D

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

D

A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having "black stools" for the last 24 hours. How would the nurse best document his reason for seeking care? a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours.

D

A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate, and he is concerned this will happen to him. How should the nurse respond? A) "The swelling in your prostate is only temporary and will go away." B) "We will treat you with chemotherapy so we can control the cancer." C) "It would be very unusual for a man your age to have cancer of the prostate." D) "The enlargement of your prostate is caused by hormone changes and not cancer."

D

A 62-year-old man states that his physician told him that he has an "inguinal hernia." He asks the nurse to explain what a hernia is. The nurse should: a. Tell him not to worry and that most men his age develop hernias. b. Explain that a hernia is often the result of prenatal growth abnormalities. c. Refer him to his physician for additional consultation because the physician made the initial diagnosis. d. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

D

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

D

A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her? a. After menopause, only women with large breasts experience sagging. b. After menopause, sagging is usually due to decreased muscle mass within the breast. c. After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

D

A 65-year-old woman is in the office for routine gynecologic care. She had a complete hysterectomy 3 months ago after cervical cancer was detected. The nurse knows that which of these statements is true with regard to this visit? A) Her cervical mucosa will be red and dry looking. B) She will not need to have a Pap smear done. C) The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. D) The nurse should plan to lubricate the instruments and the examining hand well to avoid a painful examination.

D

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: a. "Venous insufficiency is a common problem after this type of surgery." b. "Oh, you have lots of veins—you won't even notice that it has been removed." c. "You will probably experience decreased circulation after the vein is removed." d. "This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition."

D

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

D

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

D

A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, *"Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?"* The nurse's best response would be: a. "Don't worry, you still have plenty of time to develop." b. "I know just how you feel, I was a late bloomer myself. Just be patient and they will grow." c. "You will probably get your periods before you notice any significant growth in your breasts." d. "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

D

A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. "Can you tell me what they look like?" b. "Don't worry about it. You are only taking two medications." c. "How long have you been taking each of the pills?" d. "Would you have a family member bring in your medications?" .

D

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.

D

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons (skin tags), which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

D

A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.

D

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b. Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

D

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Café au lait. b. Carotenemia. c. Acrocyanosis. d. Cutis marmorata.

D

A nurse notices that a patient has abdominal ascites. What does this finding indicate? a.Flatus b.Fibroid tumors c.Presence of feces d.Presence of fluid

D

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea

D

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

D

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse diameter ratio of 1:1

D

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.

D

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect

D

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg

D

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

D

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem? a. Global aphasia b. Broca's aphasia c. Echolalia d. Wernicke's aphasia

D

A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. "It is a sharp, burning pain in my stomach." b. "I also have the sweats and nausea when I feel this pain." c. "I think this pain is telling me that something bad is wrong with me." d. "This pain happens every time I sit down to use the computer."

D

A patient is having difficulty swallowing medications and food. How should the nurse document this? a.Aphasia b.Anorexia c.Dysphasia d.Dysphagia

D

A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate? a.Ovarian infection b.Liver enlargement c.Spleen enlargement d.Kidney inflammation

D

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

D

A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? a. "Are you allergic to any other drugs?" b. "How often have you received penicillin?" c. "I'll write your allergy on your chart so you won't receive any penicillin." d. "Describe what happens to you when you take penicillin."

D

A patient's abdomen is bulging and stretched in appearance. How should the nurse document this finding? a.Obese b.Scaphoid c.Herniated d.Protuberant

D

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.

D

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight

D

A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.

D

An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a.Using the large full circle of light when assessing pupils that are not dilated b.Rotating the lens selector dial to the black numbers to compensate for astigmatism c.Using the grid on the lens aperture dial to visualize the external structures of the eye d.Rotating the lens selector dial to bring the object into focus

D

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: a. Retinal detachment. b. Diabetic retinopathy. c. Acute-angle glaucoma. d. Increased intracranial pressure.

D

Axillary nodes drain the: a. anterior abdominal wall. b. lower extremities. c. hand and lower arm. d. breast and upper arm.

D

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a.Warm the endpiece of the stethoscope by placing it in warm water. b.Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c.Ensure that the bell side of the stethoscope is turned to the "on" position. d.Check the temperature of the room, and offer blankets to the patient if he or she feels cold.

D

Blood in the fetal circulation is shunted around the lungs by way of two bypasses, which are identified as the: A. placenta and umbilicus arteriosus. B. ductus arteriosus and foramen circularus. C. foramen magnum and ductus venosus. D. foramen ovale and ductus arteriosus.

D

Characteristics of sound that are used to describe heart sounds include which of the following? a. Quality b. Tone c. Synchrony and strength d. Duration and intensity

D

During a cardiac assessment on a 38 year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty in breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? a. Fluid overload b. Atrial septal defect c. MI d. Heart failure

D

During a health history, a 22-year old woman asks, "Can I get that vaccine for HPV? I have genital warts and I'd like them to go away!" What is the nurse's best response? A) "The HPV vaccine is for girls and women ages 9 to 26, so we can start that today." B) "This vaccine is only for girls who have not started to have intercourse yet." C) "Let's check with the physician to see if you are a candidate for this vaccine." D) "The vaccine cannot protect you if you already have an HPV infection."

D

During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: a. Urgency. b. Dribbling. c. Frequency. d. Hesitancy.

D

During a history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?" The nurse should expect to see which of these upon examination of the anus? A) Rectal prolapse B) Internal hemorrhoid C) External hemorrhoid that has resolved D) External hemorrhoid that is thrombosed

D

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? a. Croup b. Tuberculosis c. Viral infection d. Pulmonary edema

D

1. A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a. Just above the diaphragm. b. Just lateral to the knee cap. c. At the level of the C7 vertebra. d. At the level of the T11 vertebra.

C

1. What is the primary purpose of the ciliated mucous membrane in the nose? a. To warm the inhaled air b. To filter out dust and bacteria c. To filter coarse particles from inhaled air d. To facilitate the movement of air through the nares

C

1. When evaluating a patients pain, the nurse knows that an example of acute pain would be: a. Arthritic pain. b. Fibromyalgia. c. Kidney stones. d. Low back pain.

C

During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: A) polyp. B) pruritus ani. C) carcinoma. D) pilonidal cyst.

D

13. A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

C

14. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Have you had any symptoms of a cold?" b. "Do you have an elevated temperature?" c. "Are you aware of having any allergies?" d. "Have you been having frequent nosebleeds?"

C

14. The nurse knows that which statement is true regarding the pain experienced by infants? a. Pain in infants can only be assessed by physiologic changes, such as an increased heart rate. b. The FPS-R can be used to assess pain in infants. c. A procedure that induces pain in adults will also induce pain in the infant. d. Infants feel pain less than do adults.

C

16. During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's Hb for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

C

17. During a well-baby checkup, the nurse notices that a 1-week-old infants face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or setting sun eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

C

18. The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a. Hyoid bone. b. Vagus nerve. c. Tragus. d. Mandible.

C

2. What are the projections in the nasal cavity that increase the surface area are called? a. Meatus b. Septum c. Turbinates d. Kiesselbach plexus

C

2. Which statement indicates that the nurse understands the pain experienced by an older adult? a. Older adults must learn to tolerate pain. b. Pain is a normal process of aging and is to be expected. c. Pain indicates a pathologic condition or an injury and is not a normal process of aging. d. Older individuals perceive pain to a lesser degree than do younger individuals.

C

20. Immediately after birth, the nurse is unable to suction the nares of a crying newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

C

21. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. What should the nurse look for during an inspection of this child's mouth? a. Swollen, red tonsils b. Ulcerations on the hard palate c. Bruising on the buccal mucosa or gums d. Small yellow papules along the hard palate

C

22. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurses hands placed firmly around his neck. b. The side with the nurses eyes averted toward the ceiling and thumbs on his neck. c. The front with the nurses thumbs placed on either side of his trachea and his head tilted forward. d. The front with the nurses thumbs placed on either side of his trachea and his head tilted backward.

C

22. The nurse is assessing a 3-year-old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

C

23. A patients thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitched tinkling; diaphragm

C

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

D

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? a. Third left intercostal space at the midclavicular line b. Fourth left intercostal space at the sternal border c. Fourth left intercostal space at the anterior axillary line d. Fifth left intercostal space at the midclavicular line

D

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Pallor near the outer canthus of the lower lid c. Yellow color of the sclera that extends up to the iris d. Presence of small brown macules on the sclera

D

23. During an assessment of a 26-year-old for "a spot on my lip I think is cancer," the clinic nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What is the most appropriate action by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

C

24. The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her babys birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum.

C

25. A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: a. Abnormal and is called the atonic neck reflex. b. Normal and should disappear by the first year of life. c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age. d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

C

26. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exophthalmos. b. Bowed long bones. c. Coarse facial features. d. Acorn-shaped cranium.

C

During an assessment, the nurse notes that the patient's apical impulse is displaced laterally, and it is palpable over a wide area. This indicates: a. Systemic hypertension. b. Pulmonic hypertension. c. Pressure overload, as in aortic stenosis. d. Volume overload, as in heart failure.

D

During an assessment, the nurse uses the CAGE test. The patient answers "yes" to two of the questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

D

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold d. Absence of drainage from the puncta when pressing against the inner orbital rim

D

During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this would be consistent with: A) a rectal polyp. B) hemorrhoids. C) a rectal fissure. D) rectal prolapse.

D

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. The nurse should: a.Document the findings in the patient's record. b.Wait 10 minutes, and auscultate the sound again. c.Ask the patient how he or she is feeling. d.Ask another nurse to double check the finding.

D

27. The nurse is assessing a patient in the hospital who has received numerous antibiotics for a lung infection and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

C

29. A woman comes to the clinic and states, Ive been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry. The nurse will assess for other signs and symptoms of: a. Cachexia. b. Parkinson syndrome. c. Myxedema. d. Scleroderma.

C

3. The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a.III b. V c. VII d. VIII

C

30. During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender.

C

34. While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a. Has chronic allergies. b. May have an infection. c. Is exhibiting a normal finding for a well child of this age. d. Should be referred for additional evaluation.

C

36. During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patients thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: a. Has an iodine deficiency. b. Is exhibiting early signs of goiter. c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy. d. Needs further testing for possible thyroid cancer.

C

4. During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which illicit substance was most commonly used? a. Crack cocaine b. Heroin c. Marijuana d. Hallucinogens

C

40. During an examination, the nurse finds that a patients left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bell palsy

C

5. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital

C

7. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odors d. Finer and less prominent nasal hair

C

8. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, Yes, Ive used marijuana at parties with my friends. What is the next question the nurse should ask? a. Who are these friends? b. Do your parents know about this? c. When was the last time you used marijuana? d. Is this a regular habit?

C

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.

C

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."

C

A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? a. You feel alone. b. You cant believe he left you alone? c. It must be so hard to face this all alone. d. I would be angry, too; raising a child alone is no picnic.

C

A 2-month-old uncircumcised infant has been brought to the clinic for a well-baby checkup. How would the nurse proceed with the genital examination? a. Eliciting the cremasteric reflex is recommended. b. The glans is assessed for redness or lesions. c. Retracting the foreskin should be avoided until the infant is 3 months old. d. Any dirt or smegma that has collected under the foreskin should be noted.

C

A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe: a. Testes that are hard and painful to palpation. b. Atrophic scrotum and a bilateral absence of the testis. c. Absence of the testis in the scrotum, but the testis can be milked down. d. Testes that migrate into the abdomen when the child squats or sits cross-legged.

C

A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a.Ask the parent to place the child on the examining table. b.Have the parent remove all of the child's clothing before the examination. c.Allow the child to keep a security object such as a toy or blanket during the examination. d.Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

C

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests: a. Normal heart. b. Systolic murmur. c. Enlargement of the left ventricle. d. Enlargement of the right ventricle.

D

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI.

D

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: a. Shallow breathing. b. Normal lung tissue. c. Decreased adipose tissue. d. Increased density of lung tissue.

D

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes.

D

During the assessment of an 18-month-old child, the mother expresses concern to the nurse about the infant's inability to toilet train. What would be the nurse's best response? A) "Some children are just more difficult to train, so I wouldn't worry about it yet." B) "Have you considered reading any of the books on toilet training? They can be very helpful." C) "This could mean there is a problem in your baby's development. We'll watch her closely for the next few months." D) "The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age."

D

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? a. "Do you have a weapon?" b. "How do other people treat you?" c. "Are you feeling so hopeless that you feel like hurting yourself now?" d. "People often feel hopeless, but the feelings resolve within a few weeks."

C

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

C

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons.

C

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: a. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema.

C

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.

C

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed? a.Document the presence of hepatomegaly. b.Ask additional health history questions regarding his alcohol intake. c.Consider this finding as normal, and proceed with the examination. d.Describe this dullness as indicative of an enlarged liver, and refer him to a physician.

C

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: a. "When was your last electrocardiogram?" b. "It's probably because it's been so hot at night." c. "Do you have any history of problems with your heart?" d. "Have you had a recent sinus infection or upper respiratory infection?"

C

A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing: a. Urinary frequency. b. Enuresis. c. Stress incontinence. d. Urge incontinence.

C

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. a. Invent; within 5 minutes b. Invent; within 30 seconds c. Recall; after a 30-minute delay d. Recall; after a 60-minute delay

C

A 46-year-old man requires assessment of his sigmoid colon. The nurse is aware that which of these is most appropriate for this examination? A) Proctoscope B) Ultrasound C) Colonoscope D) Rectal exam with an examining finger

C

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what should the nurse do? a. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope. b. Ask the patient to hold his or her breath while the nurse listens again. c. No further assessment is needed because the nurse knows this sound is an S3. d. Watch the patient's respirations while listening for the effect on the sound.

D

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.

D

A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. The nurse knows that which of these statements is correct regarding ovarian cancer? A) Ovarian cancer rarely has any symptoms. B) The Pap smear detects the presence of ovarian cancer. C) Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. D) Women over age 40 years should have a thorough pelvic examination every 3 years.

C

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.

D

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

D

In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations. c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities.

D

A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true? a. Breast masses in men are difficult to detect because of minimal breast tissue. b. Breast cancer in men rarely spreads to the lymph nodes. c. One percent of all breast cancer occurs in men. d. Most breast masses in men are diagnosed as gynecomastia.

C

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies usual childhood illnesses. b. Patient states he was a "very healthy" child. c. Patient states his sister had measles, but he didn't. d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

D

In the fetal circulation, which of the following structures is responsible for rerouting the blood in the heart? A. Foramen ellipse B. Ductus venosus C. Foramen mitrale D. Ductus arteriosus

D

Mr. Jamila is a 48-year-old patient who comes to the clinic for a cardiac risk assessment. Which of the following is not considered a risk factor for the development of CAD? A. Smoking B. Elevated blood pressure C. Obesity D. Hemoptysis

D

Mrs. Borner is a 43-year-old patient who goes to the emergency department with complaints of chest pain. When auscultating the heart, which of the following guidelines may be used to identify S2? A. S2 coincides with the R wave on the ECG. B. S2 coincides with the carotid artery pulse. C. S2 is louder at the apex than S1. D. S2 is louder at the base than S1.

D

Mrs. Cousineau is an 86-year-old woman who comes to the ambulatory clinic for a routine health assessment. On examination, which of the following cardiac assessment findings would be expected? A. A displaced apical impulse B. The presence of an S3 C. A diastolic murmur D. The presence of an S4

D

Mrs. Gorman comes to the ambulatory health centre for a routine health assessment. On examination, you perform the modified Allen test, which assesses: a. early clubbing. b. the presence of thrombophlebitis. c. the degree of pedal edema. d. the patency of the radial and ulnar arteries.

D

Pulsus bigeminus is associated with: a. aortic valve regurgitation. b. hyperkinetic states. c. heart failure. d. conduction disturbance.

D

Spirituality is defined as a. a social group that claims to possess variable traits. b. participating in religious services on a regular basis. c. the process of being raised within a culture. d. a personal effort to find meaning and purpose in life.

D

The ability of the heart to increase cardiac output is affected by: foreload and hindload. B. frontload and afterload. C. preload and postload. D. preload and afterload.

D

The electrical stimulus of the cardiac cycle follows which sequence? a. AV node SA node bundle of His b. Bundle of His AV node SA node c. SA node AV node bundle of His bundle branches d. AV node SA node bundle of His bundle branches

D

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: a. Decreased fluid volume. b. Increased cardiac output. c. Narrowing of jugular veins. d. Elevated pressure related to heart failure.

D

The first step to cultural competency by a nurse is to: a. identify the meaning of health to the patient b. understand how a health care delivery system works c. develop a frame of reference to traditional health care practices d. understand your own heritage and its basis in cultural values.

D

The inguinal nodes drain the: a. hand and lower arm. b. upper arm and breast. c. head and neck. d. anterior abdominal wall.

D

The mental status examination: a. should be completed at the end of the physical examination b. will not be affected if the patient has a language impairment c. is usually not assessed in children younger than 2 years of age d. assesses mental health strengths and coping skills and screens for any dysfunction

D

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. "Maybe she is just teething." b. "I will check her ear for an ear infection." c. "Are you sure she is really having pain?" d. "Describe what she is doing to indicate she is having pain."

D

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? a. Infant's sleeping position b. Sibling history of eating disorders c. Amount of background noise when eating d. Presence of dyspnea or diaphoresis when sucking

D

The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. a. Summary b. Closing c. Body d. Opening or introduction

D

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

D

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.

D

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.

D

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should: a.Palpate over the area for increased pain and tenderness. b.Ask the child to take shallow breaths, and percuss over the area again. c.Immediately refer the child because of an increased amount of air in the lungs. d.Consider this finding as normal for a child this age, and proceed with the examination

D

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this disorder? a.Hypertension b.Streptococcal infections c.Recurrent constipation with frequent laxative use d.Frequent use of nonsteroidal antiinflammatory drugs

D

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes

D

The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

D

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is John. I couldn't tell you where I am. I think it is 2010, though." b. "I know my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010."

D

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult? a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. c. Decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

D

The nurse is aware that what change may occur in the gastrointestinal system with aging? a.Increased salivation b.Increased liver size c.Increased esophageal emptying d.Decreased gastric acid secretion

D

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

D

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress

D

The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like? a.Flat b.Convex c.Bulging d.Concave

D

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation

D

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate? a.Asking questions enhances the child's autonomy b.Asking the child for permission helps develop a sense of trust c.This question is an appropriate statement because children at this age like to have choices d.Children at this age like to say, "No." The examiner should not offer a choice when no choice is available

D

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.

D

The nurse is examining the glans and knows which finding is normal for this area? a. The meatus may have a slight discharge when the glans is compressed. b. Hair is without pest inhabitants. c. The skin is wrinkled and without lesions. d. Smegma may be present under the foreskin of an uncircumcised male.

D

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: A) vertebral column. B) nucleus pulposus. C) vertebral foramen. D) intervertebral disks.

D

The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Obstetric history b. Childhood illnesses c. General health for the past 20 years d. Current health promotion activities

D

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: a. bend over and touch her toes. b. lie down on her left side and notice any retraction. c. shift from a supine position to a standing position; notice any lag or retraction. d. slowly lift her arms above her head and note any retraction or lag in movement.

D

The nurse is performing a genital examination on a male patient and notices urethral drainage. When collecting urethral discharge for microscopic examination and culture, the nurse should: a. Ask the patient to urinate into a sterile cup. b. Ask the patient to obtain a specimen of semen. c. Insert a cotton-tipped applicator into the urethra. d. Compress the glans between the examiner's thumb and forefinger, and collect any discharge.

D

The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm.

D

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should: a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.

D

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a.The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b.A thorough history and physical assessment information should be obtained from the patient's family member. c.A complete history and physical assessment should be immediately performed to obtain baseline information. d.Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.

D

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a.Palpation of reportedly "tender" areas are avoided because palpation in these areas may cause pain. b.Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c.The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d.The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

D

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a. Normal ABI indices are from 0.5 to 1.0. b. Normal ankle pressure is slightly lower than the brachial pressure. c. The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes. d. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.

D

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe

D

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day.

A B E

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg

A D E

contusion

A bruise; injury to tissues without breakage of skin; blood from broken blood vessels accumulates, producing pain, swelling, tenderness.

1. During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) a. Aging b. Chronic allergies c. Cigarette smoking d. Chronic alcohol use e. Herpes simplex virus I f. Frequent episodes of strep throat

A, B, C

2. A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop cold turkey. He asks the nurse, What symptoms can I expect if I do this? Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? Select all that apply. a.Headaches b.Hunger c.Sleepiness d.Restlessness e.Nervousness f.Sweating

A, B, D, E

Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy. She states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and sag slightly. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant. She reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples.

D

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

D

Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. "I broke my right leg in a car accident 2 weeks ago." b. "The pain is decreasing, but I still need to take acetaminophen." c. "I check the color of my toes every evening just like I was taught." d. "I'm able to transfer myself from the wheelchair to the bed without help."

D

Which of these statements about the anal canal is true? The anal canal: A) is about 2 cm long in the adult. B) slants backward toward the sacrum. C) contains hair and sebaceous glands. D) is the outlet for the gastrointestinal tract.

D

Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

D

Which of these statements is true regarding the penis? a. The urethral meatus is located on the ventral side of the penis. b. The prepuce is the fold of foreskin covering the shaft of the penis. c. The penis is made up of two cylindrical columns of erectile tissue. d. The corpus spongiosum expands into a cone of erectile tissue called the glans.

D

Which of these veins are responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial

D

Which statement concerning the testes is true? a. The lymphatic vessels of the testes drain into the abdominal lymph nodes. b. The vas deferens is located along the inferior portion of each testis. c. The right testis is lower than the left because the right spermatic cord is longer. d. The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

D

Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient? a. "Are you of Christian faith?" b. "Do you want to see a medicine man? c. "How often do you seek help from medical providers?" d. "What cultural or spiritual beliefs are important to you?"

D

Which structure is located in the left lower quadrant of the abdomen? a.Liver b.Duodenum c.Gallbladder d.Sigmoid colon

D

While doing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of anus is darker than surrounding skin, the anal opening is closed, and there is a skin sac that is shiny and blue. The patient mentioned that he has had pain with bowel movements and has noted some spots of blood occasionally. What would this assessment and history be most likely to indicate? A) Anal fistula B) Pilonidal cyst C) Rectal prolapse D) Thrombosed hemorrhoid

D

While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? A) Continue with the examination and document the finding in the chart. B) Instruct patient to return for repeat assessment in 1 month. C) Tell the patient that a mass was felt but it is nothing to worry about. D) Report the finding and refer the patient to a specialist for further examination.

D

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

D

How is the breast divided when doing an exam?

Four quadrants; upper inner quadrant upper outer quadrant lower inner quadrant Lower outer quadrant axillary tail of Spence

Structures in the LLQ

Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord

How does being pregnant affect the breast?

Pregnancy stimulates the expansion of the ductile system and supporting fatty tissues and development of the true secretory alveoli. This causes breast to enlarge and feel more knowledgeable. The nipples grow larger, darker and more erect

bruise

Superficial discoloration caused by hemorrhage into the tissues from ruptured blood vessels beneath the skin surface, without the skin itself being broken; also called a contusion.

a

Which would you include on the chart of the patient who has been the victim of abuse? a. photographic documentation of injuries b. a summary of the abused patient's statements c. verbatim documentation of every statement made d. a general description of injuries in the progress notes

What are the American Cancer Society's recommendations for breast health?

Women 20 to 39 years of age have a clinical breast exam every three years women 40 years and older having an annual mammogram and an annual clinical breast examination conducted close to the same time

are not

You ARE or ARE NOT required to have proof before reporting suspected abuse

intimate partner violence (IPV)

______________ ___________ _____________ can be divided into 4 main categories: physical violence, sexual violence, stalking, and psychological aggression.

lesion

a broad term referring to any pathologic or traumatic discontinuity of tissue or loss of function of a part

wound

a general term referring to a bodily injury caused by physical means

ecchymosis

a hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membrane, forming a nonelevated, rounded, or irregular blue or purplish patch.

stab wound

a penetrating, sharp, cutting injury that is deeper than it is wide

abrasion

a wound caused by rubbing the skin or mucous membrane

A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? a. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions. b. The patient should be directed to walk around the room and his blood pressure assessed after this activity. c. Blood pressure and pulse are assessed at the beginning and at the end of the examination. d. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

a.

A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: a. Allow 5 minutes for him to relax and rest before checking his vital signs. b. Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. c. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences. d. Check his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time.

a.

During an examination of a child, the nurse considers that physical growth is the best index of a child's: a. General health. b. Genetic makeup. c. Nutritional status. d. Activity and exercise patterns.

a.

The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have? a. Hypopituitary dwarfism b. Achondroplastic dwarfism c. Marfan syndrome d. Acromegaly

a.

The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patient's body stature and nutritional status b. Interpreting the subjective information the patient has reported c. Measuring the patient's temperature, pulse, respirations, and blood pressure d. Observing specific body systems while performing the physical assessment

a.

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: a. Rapid measurement is useful for uncooperative younger children. b. Using the TMT is the most accurate method for measuring body temperature in newborn infants. c. Measuring temperature using the TMT is inexpensive. d. Studies strongly support the use of the TMT in children under the age 6 years.

a.

To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip thermometer. b. Insert the thermometer 2 to 3 inches into the rectum. c. Leave the thermometer in place up to 8 minutes if the patient is febrile. d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

a.

When assessing a patient's pulse, the nurse should also notice which of these characteristics? a. Force b. Pallor c. Capillary refill time d. Timing in the cardiac cycle

a.

When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure? a. 200/92 b. 200/100 c. 100/200/92 d. 200/100/92

a.

When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? a. The body temperature of the older adult is lower than that of a younger adult. b. An older adult's body temperature is approximately the same as that of a young child. c. Body temperature depends on the type of thermometer used. d. In the older adult, the body temperature varies widely because of less effective heat control mechanisms.

a.

Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a. 1 minute, if the rhythm is irregular. b. 15 seconds and then multiplied by 4, if the rhythm is regular. c. 2 full minutes to detect any variation in amplitude. d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.

a.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

c

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that: a. Weight loss is probably the result of unhealthy eating habits. b. Chronic diseases such as hypertension cause weight loss. c. Unexplained weight loss often accompanies short-term illnesses. d. Weight loss is probably the result of a mental health dysfunction.

c.

A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination? a. Blood pressure readings are taken in both the arms and the thighs. b. The patient is assisted to a lying position, and his blood pressure is taken. c. His blood pressure is recorded in the lying, sitting, and standing positions. d. His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

c.

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is: a. "The numbers are within the normal range and are nothing to worry about." b. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." c. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts." d. "The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure."

c.

During an examination, the nurse notices that a female patient has a round "moon" face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition? a. Marfan syndrome b. Gigantism c. Cushing syndrome d. Acromegaly

c.

In a patient with acromegaly, the nurse will expect to discover which assessment findings? a. Heavy, flattened facial features b. Growth retardation and a delayed onset of puberty c. Overgrowth of bone in the face, head, hands, and feet d. Increased height and weight and delayed sexual development

c.

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? a. Increase in body weight from his younger years b. Additional deposits of fat on the thighs and lower legs c. Presence of kyphosis and flexion in the knees and hips d. Change in overall body proportion, including a longer trunk and shorter extremities

c.

The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure? a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure. b. The best position to measure thigh pressure is the supine position with the knee slightly bent. c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels.

c.

The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? a. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate. b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. d. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

c.

The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? a. A tympanic temperature is more time consuming than a rectal temperature. b. The tympanic method is more invasive and uncomfortable than the oral method. c. The risk of cross-contamination is reduced, compared with the rectal route. d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

c.

The nurse should measure rectal temperatures in which of these patients? a. School-age child b. Older adult c. Comatose adult d. Patient receiving oxygen by nasal cannula

c.

What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap? a. Diastolic blood pressure may not be heard. b. Diastolic blood pressure may be falsely low. c. Systolic blood pressure may be falsely low. d. Systolic blood pressure may be falsely high.

c.

When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: a. Is usually recorded on a 0- to 2-point scale. b. Demonstrates elasticity of the vessel wall. c. Is a reflection of the heart's stroke volume. d. Reflects the blood volume in the arteries during diastole.

c.

When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement? a. MAP is the pressure of the arterial pulse. b. MAP reflects the stroke volume of the heart. c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle. d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

c.

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by: a. Constipation. b. Patient's emotional state. c. Diurnal cycle. d. Nocturnal cycle.

c.

Mr. Harris comes to the clinic for a follow-up appointment. On examination, you note a full "bounding" pulse. This is associated with: (Select all that apply.) Select all that apply. anxiety. aortic valve stenosis. elevated temperature. hyperthyroidism. anemia. patent ductus arteriosus.

anxiety. anemia hyperthroidism elevated temperature

sexual violence (IPV)

any attempted or completed sex acts without the consent of the other person (includes: rape, unwanted sexual contact, exposure to sexual situations)

emotional abuse (child)

any pattern of behavior that harms child's emotional development or sense of self-worth; includes frequent belittling, rejection, threats, and withholding of love and support

culturally _____________ implies that caregivers apply their knowledge of culture to provide the best patient care possible.

appropriate

hemorrhage

escape of blood from a ruptured blood vessel, which can be external, internal, and/or into the skin or other organ.

neglect (elder)

failure of caregiver to prevent harm (failure to meet basic needs: hygiene, nutrition, hydration, clothing, shelter, medical care)

psychological aggression (IPV)

form of emotional abuse wherein the aggressor uses verbal or nonverbal communication to exert control or harm the person emotionally.

elder

forms of __________ abuse include the following: physical abuse, sexual abuse/abusive sexual contact, psychological/emotional abuse, neglect, financial abuse/exploitation.

sexual abuse (elder)

includes any sexual contact against the elder's will, including sexual contact with a person unable to understand the act or communicate consent.

sexual abuse (child)

includes fondling child's genitals, incest, penetration, rape, sodomy, indecent exposure, and exploitation through prostitution or production of pornographic materials

psychological abuse (elder)

includes verbal and nonverbal behavior meant to inflict fear and distress; humiliation, embarrassment, controlling behavior, social isolation, damaging/destroying property.

teen dating violence

physical, sexual, psychological, or emotional violence that occurs in a dating relationship during the adolescent years.

Tanner stage 1 girls

preadolescent no pubic hair

____________, a means of self-identification, refers to a group of people who share similar physical characteristics.

race

stalking (IPV)

repeated, unwanted attention that leads to fear (examples: repeated phone calls, spying, damaging personal property)

culturally _______________ means that caregivers are aware of different cultures in the health care setting.

sensitive

b

should you: a. speculate on what caused an injury b. document what you observed and what the victim said

Structures in RLQ

cecum appendix right ovary and tube right ureter right spermatic cord

culturally ___________ means that caregivers understand all aspects of the patient's cultural being, and this include this information in the patient's care.

competent

The nurse is performing a general survey of a patient. Which finding is considered normal? a. When standing, the patient's base is narrow. b. The patient appears older than his stated age. c. Arm span (fingertip to fingertip) is greater than the height. d. Arm span (fingertip to fingertip) equals the patient's height.

d.

When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: a. Assume that the patient is eager and interested in participating in the interview. b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. c. Assume that the patient is having difficulty breathing and assist him to a supine position. d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

d.

When checking for proper blood pressure cuff size, which guideline is correct? a. The standard cuff size is appropriate for all sizes. b. The length of the rubber bladder should equal 80% of the arm circumference. c. The width of the rubber bladder should equal 80% of the arm circumference. d. The width of the rubber bladder should equal 40% of the arm circumference.

d.

When measuring a patient's weight, the nurse is aware of which of these guidelines? a. The patient is always weighed wearing only his or her undergarments. b. The type of scale does not matter, as long as the weights are similar from day to day. c. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight. d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

d.

While measuring a patient's blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure. a. Pulse rate b. Pulse pressure c. Vascular output d. Peripheral vascular resistance

d.

a broad term focused on a connection to something larger than oneself, and a belief in transcendence.

spirituality

puncture

the act of piercing or penetrating with a pointed object or instrument

neglect (child)

the failure to provide for child's basic needs (physical, medical, and supervision) [also includes prenatal drug exposure, child abandonment, and manufacturing of amphetamines, failure to educate the child, in some states]

avulsion

the tearing away of a structure or part

physical violence (IPV)

the use of force that could cause death, disability, or injury

true

true or false: verbatim documentation of the reported perpetrator's threats interlaced with curses and expletives can be useful in future court proceedings.

financial abuse (elder)

unauthorized or improper use of the elder's resources for monetary or personal benefit, profit or gain, such as forgery, theft, or improper use of guardianship or power of attorney.

pattern of injuries

usually bruises and fractures in various stages of healing

physical abuse (elder)

when an elder is intentionally injured, assaulted, threatened with a weapon, or inappropriately restrained.

in the ________ __________ theory of health, health exists when all aspects of the person are in perfect balance.

yin yang

should not

you SHOULD or SHOULD NOT sanitize the words reportedly heard by a victim.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber- yellow in color and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that: 1. this is most likely a serous otitis media. 2. the child has an acute purulent otitis media. 3. there is evidence of a resolving cholesteatoma. 4. the child is experiencing the early stages of perforation.

1

Which of the following statements is true concerning air conduction? 1. It is the most efficient pathway for hearing. 2. It is caused by the vibrations of bones in the skull. 3. The amplitude of sound determines the pitch that is heard. 4. A loss of air conduction is called a conductive hearing loss.

1

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history? 1. "Does your baby seem to startle with loud noise?" 2. "Has the baby had any surgeries on the ears?" 3. "Have you noticed any drainage from her ears?" 4. "How many ear infections has your baby had since birth?"

1

The portion of the ear that consists of movable cartilage and skin is called the: 1. auricle. 2. concha. 3. outer meatus. 4. mastoid process.

1

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: 1.height and weight. 2.leg circumference. 3.biceps skinfold thickness. 4.hip and waist measurement.

1

The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? 1.The absorption of nutrients may be impaired. 2.The constipation may represent a food allergy. 3.She may need emergency surgery for the problem. 4.The gastrointestinal problem will increase her caloric demand.

1

The nurse is providing nutrition information to the mother of a 1-year-old child. Which of the following statements represents accurate information for this age group? 1.It is important to maintain adequate fat and caloric intake. 2.The recommended dietary allowances for an infant are the same as for an adolescent. 3.At this age the baby's growth is minimal so caloric requirements are decreased. 4.The baby should be placed on skim milk to decrease the risk of coronary artery disease when older.

1

The nurse recognizes that which of the following persons is at greatest risk for undernutrition? 1. A 5-month-old infant 2. A 50-year-old woman 3. A 20-year-old college student 4. A 30-year-old hospital administrator

1

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: 1. otosclerosis. 2. presbycusis. 3. trauma to the bones. 4. frequent ear infections.

1

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? 1. This should not be used in an 80-year-old patient. 2. This technique is helpful in assessing for otitis media. 3. This is especially useful in assessing a patient with an upper respiratory infection. 4. This will cause the eardrum to bulge slightly and make landmarks more visible.

1

A patient states that she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC>BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What would be the interpretation of these results? 1. The patient may have sensorineural loss. 2. The test results are reflective of normal hearing. 3. Conduction of sound through bones is impaired. 4. These results make no sense, so further tests should be done.

1

After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may be deficient in iron. Laboratory studies to obtain to verify this condition would be: 1.hemoglobin and hematocrit. 2.cholesterol and triglycerides. 3.creatinine and serum protein. 4.serum albumin and urinary urea nitrogen.

1

During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? 1.Certain drugs can affect the metabolism of nutrients. 2.The nurse needs to assess the patient for allergic reactions. 3.Medications need to be documented on the record for the physician's review. 4.Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

1

During the ear examination of an 80-year-old patient, which of the following would be a normal finding? 1. A high-tone frequency loss 2. Increased elasticity of the pinna 3. A thin, translucent membrane 4. A shiny, pink tympanic membrane

1

If a 29-year-old woman weighs 146 pounds and the nurse determines her ideal body weight to be 120 pounds, how would the nurse classify the woman's weight? 1.Obese 2.Mildly overweight 3.Suffering from malnutrition 4.Within appropriate range of ideal weight

1

In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: 1.height and weight. 2.frame size and weight. 3.waist and hip circumferences. 4.mid upper arm circumference and arm span.

1

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? 1. The infant turns the head to localize sound. 2. No obvious response to noise 3. A startle and acoustic blink reflex 4. The infant stops movement and appears to listen.

1

The nurse is evaluating patients for obesity-related diseases. Which one of the following would be at increased risk? 1.A 29-year-old woman whose percent ideal body weight is 125%, waist is 33 inches, and hips 36 inches 2.A 32-year-old man whose percent ideal body weight is 115%, waist is 34 inches, and hips 36 inches 3.A 38-year-old man whose percent ideal body weight is 120%, waist is 35 inches, and hips 38 inches 4.A 46-year old woman whose percent ideal body weight is 130%, waist is 30 inches, and hips 38 inches

1

The nurse is performing a nutritional assessment on a 15-year-old girl, who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse's appropriate response would be: 1."How much do you think you should weigh?" 2."Don't worry about it, you're not that overweight." 3."The best thing for you would be to go on a diet." 4."I used to always think I was fat when I was your age."

1

The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes that directly affect the nutritional status of the elderly include: 1.slowed gastrointestinal motility. 2.hyperstimulation of the salivary glands. 3.an increased sensitivity to spicy and aromatic foods. 4.decreased gastrointestinal absorption causing esophageal reflux.

1

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure? 1. Pull the pinna down. 2. Pull the pinna up and back. 3. Tilt the child's head slightly toward the examiner. 4. Have the child touch his chin to his chest.

1

Which of the following best describes the technique for measuring frame size? 1.With the patient standing, measure the distance from the top of the head to the back of the heel. 2.With the patient in a sitting position, measure the distance from the condyle of the humerus to the clavicle. 3.With the patient's right arm extended forward and the elbow extended, measure the distance from fingertips to the condyle of the humerus. 4.With the right arm extended forward and the elbow bent, use the calipers to measure the distance between the condyles of the humerus.

4

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) 1. Hearing loss related to aging begins in the mid 40s. 2. The progression is slow. 3. The aging person has low-frequency tone loss. 4. The aging person may find it harder to hear consonants than vowels. 5. Sounds may be garbled and difficult to localize. 6. Hearing loss reflects nerve degeneration of the middle ear.

2, 4, 5

Which of the following individuals is most likely to have an anergic response when assessing skin test antigens? 1.An 8-year-old child 2.An obese individual 3.A healthy 80-year-old female 4.An individual with malnutrition

4

Which of the following is a risk factor for ear infections in young children? 1. Family history 2. Air conditioning 3. Excessive cerumen 4. Secondhand cigarette smoke

4

Which of the following measurements is an early indicator of protein malnutrition? 1.Serum albumin 2.Serum creatinine 3.Nitrogen balance 4.Serum transferrin

4

Which of the following statements concerning the eustachian tube is true? 1. It is responsible for the production of cerumen. 2. It remains open except when swallowing or yawning. 3. It allows passage of air between the middle and outer ear. 4. It helps equalize air pressure on both sides of the tympanic membrane.

4

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? 1. "It is unusual for a small child to have frequent ear infections unless there is something else wrong." 2. "We need to check the immune system of your son to see why he is having so many ear infections." 3. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." 4. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

4

The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of the following foods are recommended? 1.Foods that the child will eat, no matter what they are 2.Foods easy to hold such as hot dogs, nuts, and grapes 3.Any foods as long as the rest of the family is eating them 4.Finger foods and nutritious snacks that can't cause choking.

4

The nurse is seeing a patient for the first time who has no history of nutrition-related problems. The initial nutritional screening should include which of the following? 1.Calorie count of nutrients 2.Anthropometric measures 3.Complete physical examination 4.Measurement of weight and weight history

4

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? 1. "Do you ever notice ringing or crackling in your ears?" 2. "When was the last time you had your hearing checked?" 3. "Have you ever been told you have any type of hearing loss?" 4. "Was there any relationship between the ear pain and the discharge you mentioned?"

4

When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is: 1.nutrients in excess of daily body requirements. 2.sufficient nutrients to provide for the minimum body needs. 3.sufficient nutrients for daily body requirements but not for increased metabolic demands. 4.sufficient nutrients to provide for daily body requirements and for increased metabolic demands.

4

When assessing muscle mass and fat stores on a 40-year-old woman, the nurse would use: 1.triceps skinfold. 2.mid arm muscle area. 3.percent ideal body weight. 4.mid upper arm circumference.

4

Which body composition-measuring tool measures fat and lean body mass and bone mineral density? 1.Waist-to-hip ratio 2.Body mass index 3.Bioelectrical impedance analysis 4.Dual-energy x-ray (DEXA) absorptiometry

4

In an individual with otitis externa, which of the following signs would the nurse expect to find on assessment? 1. Rhinorrhea 2. Periorbital edema 3. Pain over the maxillary sinuses 4. Enlarged superficial cervical nodes

4

In performing an examination of a 3-year-old with a suspected ear infection, the nurse would: 1. omit the otoscopic exam if the child has a fever. 2. pull the ear up and back before inserting the speculum. 3. ask the mother to leave the room while examining the child. 4. perform the otoscopic examination at the end of the assessment.

4

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? 1. The tubes are placed in the inner ear. 2. The tubes are used in children with sensorineural loss. 3. The tubes are permanently inserted during a surgical procedure. 4. The purpose of the tubes is to decrease the pressure and allow for drainage.

4

A 40-year-old man has had a recent weight loss of 20 pounds because of a quick loss diet and stress. He tells the nurse that he keeps getting "colds and the flu." In addition to assessing his nutrition status, the nurse would also want to obtain which laboratory report? 1.Serum albumin 2.Cholesterol level 3.Serum transferrin 4.Total lymphocyte count

4

A patient is asked to indicate on a form how many times he eats a specific food. This would describe which of the following methods for obtaining dietary information? 1.Food diary 2.Calorie count 3.24-hour recall 4.Food frequency questionnaire

4

A pregnant woman is interested in breast-feeding her baby, and asks several questions about the topic. Which information is appropriate for the nurse to share with her? 1.Breast-feeding is best when also supplemented with bottle feedings. 2.Babies who are breastfed often require supplemental vitamins. 3.Breast-feeding is recommended for infants for the first 2 years of life. 4.Breast milk provides the nutrients necessary for growth as well as natural immunity.

4

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of the following? 1. Any change in the ability to hear 2. Any recent drainage from the ear 3. Recent history of trauma to the ear 4. Any prolonged exposure to extreme cold

4

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is: 1. the cochlea. 2. cranial nerve VIII. 3. the organ of Corti. 4. the bony labyrinth.

4

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? 1. Malignancy 2. Viral infection 3. Blood in the middle ear 4. Yeast or fungal infection

4

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

A, D, E

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. b. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. e. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

A C D

When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the health care needs of others. These discrete areas include understanding of (Select all that apply.) a. his or her own heritage b. cultural and ethnic values c. heritage of the health system d. heritage of the nursing profession e. the heritage of the patient

A C D E

A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see. The nurse examines him, and finds that he has scrotal swelling on the left side. He had the mumps the previous week, and the nurse suspects that he has orchitis. Which of the following assessment findings support this diagnosis? Select all that apply. a. Swollen testis b. Mass that transilluminates c. Mass that does not transilluminate d. Scrotum that is nontender upon palpation e. Scrotum that is tender upon palpation f. Scrotal skin that is reddened

A,C, E, F

incision

A cut or wound made by a sharp instrument; the act of cutting

hematoma

A localized collection of extravasated blood, usually clotted in an organ, space, or tissue

The nurse is performing a digital examination of a patient's prostate gland and notices that characteristics of a normal prostate gland include which of the following? Select all that apply. A) The gland protruding 1 cm into the rectum B) Heart-shaped with a palpable central groove C) Flat with no groove palpable D) Boggy and soft consistency E) Smooth surface, elastic, or rubbery consistency F) Fixed mobility

A, B, E

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. a. Develops over a short period. b. Person is experiencing apraxia. c. Person is exhibiting memory impairment or deficits. d. Occurs as a result of a medical condition, such as systemic infection. e. Person is experiencing agnosia.

A, C, D

The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. "Where is the headache pain?" b. "Did you have these headaches as a child?" c. "On a scale of 1 to 10, how bad is the pain?" d. "How often do the headaches occur?" e. "What makes the headaches feel better?" f. "Do you have any family history of headaches?"

A, C, D, E

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply. a.Warm the hands first before touching the patient. b.For deep palpation, use one long continuous palpation when assessing the liver. c.Start with light palpation to detect surface characteristics. d.Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps. e.Identify any tender areas, and palpate them last. f.Use the palms of the hands to assess temperature of the skin.

A, C, D, E

The nurse is examining a 62-year-old man and notes that he has gynecomastia bilaterally. The nurse should explore his history for which related conditions? *Select all that apply.* a. Obesity b. Malnutrition c. Hyperthyroidism d. Type 2 diabetes mellitus e. Liver disease f. History of alcohol abuse

A, C, E, F

A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? Select all that apply. a. Blood test for prostate-specific antigen (PSA) b. Urinalysis c. Transrectal ultrasound d. Digital rectal examination (DRE) e. Prostate biopsy

A, D

1. During assessment of a patients pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. a. Sleeping b. Moaning c. Diaphoresis d. Bracing e. Restlessness f. Rubbing

A, D, F

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse keeps in mind that characteristics of a cancerous mass include which of the following? *Select all that apply.* a. Nontender mass b. Dull, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border

A, D, F

Tanner Stage 3 girls

Breast an Ariola and large, the nipple is flush with the breast surface

Tanner stage 2 girls

Breast buds with areolar enlargement Pubic hair sparse

Lymph nodes are palpable in: adults with infections. All of the options. children with infections. healthy children.

All of the options.

The blood is returned to the heart through the veins by means of: All of the options. breathing. unidirectional valves. walking.

All of the options.

patterned injury

An injury caused by an object that leaves a distinct pattern on the skin and/or organ (e.g., being whipped with an extension cord) or an injury caused by a unique mechanism of injury (e.g., immersion burns to the hands [glove burns] or feet [sock burns]).

Tanner stage 4 girls

Areola and nipple projects as secondary mound Pubic hair is more coarse - no triangle yet

1. A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? Select all that apply. a. Bradycardia b. Coarse tremor of the hands c. Transient hallucinations d. Somnolence e. Sweating

B, C, E

2. During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. a. Ask the patient, Do you have pain? b. Assess the patients breathing independent of vocalization. c. Note whether the patient is calling out, groaning, or crying. d. Have the patient rate pain on a 1-to-10 scale. e. Observe the patients body language for pacing and agitation.

B, C, E

The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. a. "How much junk food does your child eat?" b. "How many teeth has he lost, and when did he lose them?" c. "Is he able to tie his shoelaces?" d. "Does he take a children's vitamin?" e. "Can he tell time?" f. "Does he have any food allergies?"

B, C, E

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood

B, C, E, F

10. The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.

D

11. The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae.

D

Mr. Jankowski comes to your clinic with his child, who has been studying about the thymus gland in school. She is correct when she tells you the following is/are true about the thymus gland. (Select all that apply.) Select all that apply. Develops T-lymphocytes The gland atrophies after puberty. Is vital to the immune system Develops B-lymphocytes

Develops T-lymphocytes The gland atrophies after puberty Is vital to the immune system

b

During an interview, a woman has answered "yes" to 3 of the Abuse Assessment Screen questions. How should you proceed? a. ask the patient if she has filed a restraining order b. proceed by asking more questions about the items she answered "yes." c. respond by confirming that the patient was abused d. interview the woman's partner and compare notes

How does being overweight affect development and girls?

Girls Who are overweight or obese BMI levels have a significantly higher occurrence of early breast budding and early menarche

petechiae

Minute, pinpoint, nonraised, perfectly round purplish-red spots caused by intradermal or submucous hemorrhage, which later turn blue or yellow.

Tanner stage 5 girls

Mature breasts. Only the nipple protrudes, the Ariola is flush with the breast contour

Structures in the LUQ

Stomach Spleen Left lobe of liver Body of Pancreas Left kidney and adrenal Splenic flexure of colon Part of Transverse and descending colon

laceration

The act of tearing or splitting; a wound produced by the tearing and/or splitting of body tissue, usually from blunt impact over a bony surface.

*Menarche* refers to

The beginning of menstruation

d

Which clinical situation would require the examiner to report to the proper authorities? a. statements from the victim b. statements from witnesses c. proof of abuse/or neglect d. suspicion of elder abuse and/or neglect

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? a. Wait 30 minutes if the patient has ingested hot or iced liquids. b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips. d. Shake the mercury-in-glass thermometer down to below 36.6° C before taking the temperature.

b.

While measuring a patient's blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply. a. The person supports his or her own arm during the blood pressure reading. b. The blood pressure cuff is too narrow for the extremity. c. The arm is held above level of the heart. d. The cuff is loosely wrapped around the arm. e. The person is sitting with his or her legs crossed. f. The nurse does not inflate the cuff high enough.

a. b. d. e.

_________________ is the process of adopting the culture and behavior of the majority culture.

acculturation

A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings? a. These readings are a normal response and attributable to changes in the patient's position. b. The change in blood pressure readings is called orthostatic hypotension. c. The blood pressure reading in the lying position is within normal limits. d. The change in blood pressure readings is considered within normal limits for the patient's age.

b.

A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: a. After menopause, blood pressure readings in women are usually lower than those taken in men. b. The blood pressure of a Black adult is usually higher than that of a White adult of the same age. c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight. d. A teenager's blood pressure reading will be lower than that of an adult.

b.

A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? a. Normal blood pressure b. Prehypertension c. stage 1 hypertension d. Stage 2 hypertension

b.

The nurse has collected the following information on a patient: palpated blood pressure-180 mm Hg; auscultated blood pressure-170/100 mm Hg; apical pulse-60 beats per minute; radial pulse-70 beats per minute. What is the patient's pulse pressure? a. 10 b. 70 c. 80 d. 100

b.

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36° C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results? a. The patient is experiencing tachycardia. b. These are normal vital signs for a healthy, athletic adult. c. The patient's pulse rate is not normal—his physician should be notified. d. On the basis of these readings, the patient should return to the clinic in 1 week.

b.

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? a. The pulse is more difficult to palpate because of the stiffness of the blood vessels. b. An increased respiratory rate and a shallower inspiratory phase are expected findings. c. A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures. d. Changes in the body's temperature regulatory mechanism leave the older person more likely to develop a fever.

b.

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body? a. Exercise b. Radiation c. Metabolism d. Food digestion

b.

The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: a. Yield a falsely low blood pressure. b. Yield a falsely high blood pressure. c. Be the same, regardless of cuff size. d. Vary as a result of the technique of the person performing the assessment.

b.

The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: a. More clearly hear the Korotkoff sounds. b. Detect the presence of an auscultatory gap. c. Avoid missing a falsely elevated blood pressure. d. More readily identify phase IV of the Korotkoff sounds.

b.

When assessing an older adult, which vital sign changes occur with aging? a. Increase in pulse rate b. Widened pulse pressure c. Increase in body temperature d. Decrease in diastolic blood pressure

b.

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to: a. Immediately notify the physician. b. Consider this finding normal in children and young adults. c. Check the child's blood pressure, and note any variation with respiration. d. Document that this child has bradycardia, and continue with the assessment.

b.

the ________________ theory of illness assumes that all events in life have a cause and effect (example: germ theory)

biomedical

Gynecomastia is:

overdevelopment of breast tissue in males

_______________ ______________ ensures that non-native English speaking patients receive care in a manner in which they linguistically understand.

linguistic competence

Structures in RUQ

liver gallbladder duodenum head of pancreas right kidney and adrenal hepatic flexure of colon part of ascending and transverse colon

traumatic alopecia

loss of hair from pulling and yanking or by other traumatic means

the __________________ perspective of illness depends on supernatural forces of good and evil.

magicoreligious

supernumerary nipple

minute extra nipple along the embryonic milk line

the ________________ theory of illness is the belief that the forces of nature must be kept in natural balance or harmony (example: ying yang, hot cold)

naturalistic

physical abuse (child)

nonaccidental physical injury caused by punching beating, kicking, biting, burning, shaking, or otherwise harming a child.

a social group within the social system that claims to possess variable traits such as common geographic origin, migratory status, and religion.

ethnicity

the _______ _______ theory of health is an explanatory model with origins in the ancient greek humoral theory.

hot cold

A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department

A

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said

A

A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.

A

. During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. b. This question is an innocent search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior.

A

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing

A

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.

A

As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d. I can see that you are very upset. Perhaps we should discuss this later.

A

Barriers to incorporating EBP include: a. Nurses lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills.

A

Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning.

A

In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a. Note-taking may impede the nurses observation of the patients nonverbal behaviors. b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.

A

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.

A

The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off televisions and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less c. Provides a dim light that makes the room cozy and helps the patient relax d. Arranges seating across a desk or table to allow the patient some personal space

A

The patients record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary.

A

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he is ready. b. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains. c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there? d. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time.

A

The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute

A, C, E, F

A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up.

B

A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.

B

A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.

B

A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: a. Go on, Im listening. b. Fits? Tell me what you mean by this. c. Yes, it can be upsetting when a child has a fit. d. Dont be upset when he has a fit; every 2 year old has fits.

B

Each culture has its own healers who usually a. own and operate specialty community clinics. b. cost less than traditional or biomedical providers. c. recommend folk practices that are dangerous. d. speak at least two languages.

B

The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurses conclusion on the basis of the patients nonverbal response.

B

The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors.

B

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: a. Excited about her pregnancy but nervous about the labor. b. Exhibiting verbal and nonverbal behaviors that do not match. c. Excited about her pregnancy, but her husband is not and this is upsetting to her. d. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.

B

The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. Did we forget something? b. Is there anything else you would like to mention? c. I need to go on to the next patient. Ill be back. d. While Im here, lets talk about your upcoming surgery.

B

What is the yin/yang theory of health? a. Health exists in the absence of illness. b. Health exists when all aspects of the person are in perfect balance. c. Health exists when physical, psychological, spiritual, and social needs are met. d. Health exists when there is optimal functioning.

B

When completing a health assessment, which of the following actions most demonstrates cultural competence? a. Ask about family history of diseases. b. Ask about use of traditional, herbal, or folk remedies. c. Make sure the blood pressure cuff fits appropriately. d. Measure height and weight in a private room.

B

Which critical thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant

B

While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following would most likely describe this patient's view of wellness? a. The phlegm will be replaced with dryness. b. The humors must be balanced. c. Good is hot. d. Evil is hot.

B

. The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? a. This comment is inappropriate because it shows the nurses bias. b. This comment is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

C

4. A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? a. Confusion b. Hyperventilation c. Increased blood pressure and pulse d. Depression

C

A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d. Using blunt language to deal with distasteful topics.

C

A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.

C

A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly

C

During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d. It sounds as though you have made your decision. I think it is a good one.

C

Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? a. Well-adjusted adolescent who came in for a sports physical b. Recovering alcoholic who came in for a basic physical examination c. Man whose wife has just been diagnosed with lung cancer d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him

C

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs

C

When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a. Immediately notify the patients physician. b. Document the sound exactly as it was heard. c. Validate the data by asking a coworker to listen to the breath sounds. d. Assess again in 20 minutes to note whether the sound is still present.

C

Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment

C

13. A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? a. Completing the physical examination first and then giving the pain medication b. Telling the patient that the pain medication must wait until after the x-ray images are completed c. Evaluating the full range of motion of the knee and then medicating for pain d. Administering pain medication and then proceeding with the assessment

D

15. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: a. Referred. b. Cutaneous. c. Visceral. d. Deep somatic.

D

3. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this childs pain? a. Descriptor Scale b. Numeric rating scale c. Brief Pain Inventory d. Faces Pain ScaleRevised (FPS-R)

D

5. A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the: a. Affected extremity will eventually regain its function. b. Pain is felt at one site but originates from another location. c. Patients pain will be associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.

D

6. The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the: a.Patients vital signs. b.Physical examination. c.Results of a computerized axial tomographic scan. d.Subjective report.

D

7. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is bad this morning and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: a.Is addicted to her pain medications and cannot obtain pain relief. b. Does not want to trouble the nursing staff with her complaints. c. Is not in pain but rates it high to receive pain medication. d. Has experienced chronic pain for years and has adapted to it.

D

8. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? a. Visceral b. Referred c. Cutaneous d. Neuropathic

D

9. When assessing the quality of a patients pain, the nurse should ask which question? a. When did the pain start? b. Is the pain a stabbing pain? c. Is it a sharp pain or dull pain? d. What does your pain feel like?

D

A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual. d. Provide culturally sensitive and appropriate care.

D

A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a. The woman is nervous and embarrassed. b. She has something to hide and is ashamed. c. The woman is showing inconsistent verbal and nonverbal behaviors. d. She is showing that she is carefully listening to what the nurse is saying.

D

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: a. Stop that immediately! b. Oh, you are too funny. Lets keep going with the interview. c. Do you really think I would be interested? d. It makes me uncomfortable when you talk that way. Please stop.

D

A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. How is your family? b. How is your job? c. Tell me about your hypertension. d. How has your health been since your last visit?

D

A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. Mr. K., I know that you are lying. b. Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.

D

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. Mr. Y., at your age, surely you have been hospitalized before! b. Mr. Y., I just need permission to get your medical records from County Medical. c. Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that? d. Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?

D

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. Hello, Nancy, my name is Mrs. C. b. Hello, Mrs. H., my name is Mrs. C. It sure is cold today! c. Mrs. H., my name is Mrs. C. How are you? d. Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.

D

During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies.

D

During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

D

During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: a. Simply changing positions. b. More comfortable in this position. c. Tired and needs a break from the interview. d. Uncomfortable talking about his sons treatment.

D

During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question

D

During the interview portion of data collection, the nurse collects __________ data. a. Physical b. Historical c. Objective d. Subjective

D

In the health promotion model, the focus of the health professional includes: a. Changing the patients perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. Helping the consumer choose a healthier lifestyle.

D

In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation.

D

The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

D

When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

D

When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patients health state. d. Holistic health views the mind, body, and spirit as interdependent.

D

Which of the social determinants of health has the greatest influence on a person's health? a. work environment b. neighborhood c. education d. poverty

D

Which situation is most appropriate during which the nurse performs a focused or problem-centered history? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms.

D

Which statement best describes a proficient nurse? A proficient nurse is one who: a. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.

D

an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as attendance at regular services.

religion

the process of being raised within a culture and acquiring the characteristics of that group

socialization