TEST 4: Chapter 31 Mastering (Fundamentals of Nursing)

The nurse is performing a Mini-Mental State Examination (MMSE) on an alcoholic patient. Which parameter can be assessed by the MMSE?

A. Alcohol content of blood B. Sensory and motor deficits C. Risk of development of seizures *D. Orientation and cognitive function RATIONALE: A Mini-Mental State Examination (MMSE) helps to assess orientation and cognitive function of the patient by asking specific questions. The maximum score is 30. A score of 21 or less indicates a cognitive impairment. The MMSE is not useful to assess alcohol content of blood, because the alcohol content can be tested by laboratory tests. Sensory and motor deficits can be assessed by testing reflexes. The risk of development of seizures cannot be tested by MMSE.

Which physical findings of the skin may indicate phencyclidine abuse?

A. Diaphoresis *B. Red, dry skin C. Needle marks D. Spider angiomas RATIONALE: Red and dry skin indicates phencyclidine abuse. Diaphoresis indicates sedative hypnotic abuse. Needle marks on the skin indicate opioid substance abuse. Spider angiomas indicate alcohol abuse.

What characteristic of the hair is due to androgen hormone stimulation?

A. Dull *B. Oily C. Brittle D. Thinning

Which portion of the hand is used to assess the thickness of skin?

A. Finger pads *B. Palmar surface C. Dorsum D. Fingertips RATIONALE: The palmar surface of the hand is used to assess the thickness of skin. Finger pads are used to assess the tenderness of skin. The dorsum of the hand is used to assess temperature. Grasping with fingertips is used to measure the turgor and elasticity of skin.

A nurse instructs a patient to assume the lithotomy position. For what does the nurse plan to assess?

A. Heart B. Rectum and vagina C. Musculoskeletal system *D. Genitalia and genital tract RATIONALE: The lithotomy position provides maximum exposure of female genitalia and facilitates the insertion of a vaginal speculum. While assessing the heart, the patient should be asked to assume the lateral recumbent position. While assessing the rectum and vagina, the patient should be asked to assume the Sims' position. While assessing the musculoskeletal system, the patient should be asked to assume a prone position. TEST-TAKING TIP: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which is the best site to inspect for jaundice?

A. Lips *B. Sclera C. Nail beds D. Arms RATIONALE: Of these sites, the sclera are the best for inspecting for jaundice, a yellow-orange discoloration. The lips and nail beds may be inspected for cyanosis and pallor. The arms may be inspected for a lack of pigmentation.

What is the imaginary line observed in the anterior chest landmarks?

A. Midaxillary line *B. Midclavicular line C. Right scapular line D. Posterior axillary line RATIONALE: The midclavicular line is the imaginary line observed in the anterior chest landmark. The midaxillary line is the imaginary line observed in the lateral chest landmark. The right scapular line is the imaginary line observed in the posterior chest landmark. The posterior axillary line is the imaginary line observed in lateral chest landmarks.

The nurse is performing a respiratory assessment based on the imaginary lines on the posterior chest landmark. Which line would the nurse use for assessment?

A. Midaxillary line B. Midsternal line *C. Left scapular line D. Posterior axillary line RATIONALE: The left scapular line is the imaginary line on the posterior chest landmark. The midaxillary line is the imaginary line on the lateral chest landmark. The midsternal line is the imaginary line on the anterior chest landmark. The posterior axillary line is the imaginary line on the lateral chest landmark.

Which cranial nerve controls the position of the tongue?

A. Olfactory B. Trochlear C. Abducens *D. Hypoglossal RATIONALE: The hypoglossal nerve controls the position of the tongue. The olfactory nerve is associated with the sense of smell. The troclear nerve is associated with downward, inward eye movements. The abducens nerve is associated with lateral movement of the eyeballs.

Which cranial nerve is responsible for the sense of smell?

A. Vagus *B. Olfactory C. Trochlear D. Trigeminal RATIONALE: The olfactory cranial nerve is responsible for the sense of smell. The vagus nerve is responsible for the sensation of the pharynx. The trochlear nerve is responsible for downward and inward eye movements. The trigeminal nerve is responsible for the sensory nerve innervation of the face.

Which symptom may indicate hyperthyroidism?

*A. Bulging eyes B. Crossed eyes C. Inflamed eyes D. Blurry eyes RATIONALE: Bulging eyes may indicate hyperthyroidism. Crossed eyes indicate neuromuscular injury. Inflamed eyes may indicate a variety of causes, including infections, irritation from foreign matter, dryness, or allergic reactions. Blurry eyes may result from macular degeneration.

Which term is used for an abnormal drooping of the lid over the pupil?

*A. Ptosis B. Ectropion C. Entropion D. Nystagmus RATIONALE: Ptosis is an abnormal drooping of the lid over the pupil. It is caused by edema or impairment of the third cranial nerve. Ectropion is the turning out of the lid margins. Entropion is the turning in of the lid margins. Nystagmus is involuntary oscillation of the eyes.

A patient's nose is bleeding. What should the nurse assess to help determine the cause of the bleeding?

*A. The mucosa B. Symmetry of the nose C. The septum for deviation D. The septum for perforation RATIONALE: The nurse should inspect the patient's nasal mucosa to determine the cause of the bleeding. The nurse should assess for symmetry of the nose to identify any deformity. The deviation of the septum should be inspected if the patient has any discomfort while breathing. The nurse would look for nasal septum perforation if repeated cocaine use was suspected.

A patient undergoes Romberg's test. When is a Romberg's test considered negative?

*A. The patient is able to stand rigidly without swaying. B. The patient tends to move the head toward the dominant side. C. The patient is unable to touch the end of the nose with the finger. D. The patient sways towards the side and loses balance. RATIONALE: Romberg's test requires that a patient stand with eyes closed without swaying. A negative Romberg's test is considered normal. The patient moving the head toward the dominant side is not a part of the assessment. The patient touching the end of the nose with fingers is not a part of the assessment. The patient losing balance and falling to one side indicates a positive Romberg's test.

Which is not a function of the lymph nodes?

*A. Secrete hormones B. Protect the body from foreign antigens C. Remove damaged cells from circulation D. Provide a partial barrier to malignant cell growth RATIONALE: Lymph nodes are a part of the immune system, not the endocrine system, which encompasses glands that secrete the body's hormones. As a part of the immune system, the lymph nodes do protect the body from foreign antigens, remove damaged cells from circulation, and provide a partial barrier to malignant cell growth.

A nurse is examining a patient's skin using palpation. Which action made by the nurse needs correction?

*A. Checking the patient's skin turgor and elasticity by using the dorsum of the hand B. Checking the patient's skin texture using the palmar surface of the hand C. Checking the patient's skin thickness with the palmar surface of the hand D. Checking the patient's temperature using the dorsum of the hand or fingers RATIONALE: The nurse should check Skin turgor and elasticity by grasping the skin with fingertips, not by using the dorsum of the hand. Skin texture and thickness should be assessed by using the palmar surface of the hand. Temperature should be checked by using the dorsum of the hand or fingers.

Which type of muscles do women commonly use to breathe?

*A. Costal B. Trapezius C. Abdominal D. Diaphragm RATIONALE: Women tend to use their costal muscles to breathe. The trapezius and abdominal muscles are not used for breathing in healthy patients. Men, not women, tend to use their diaphragms to breathe.

A nurse is teaching a child's parent about precautions to follow in providing effective care to the child who has frequent nosebleeds. Which of the parent's statements indicates a need for further teaching?

*A. "I should instruct my child to breathe slowly through the nose." B. "I should apply pressure to the anterior nose with my thumb." C. "I should apply ice to the nose bridge if the bleeding continues after pressure has been applied." D. "I should make my child sit up and lean forward when a nosebleed occurs." RATIONALE: The parent should instruct the child to breathe through the mouth, not the nose, because it may be difficult to breathe nasally when there is bleeding. The other statements indicate effective learning: The parent should be instructed to apply pressure to the anterior nose with the thumb and forefinger as the child breathes through the mouth. The parent should apply ice or a cold cloth to the bridge of the nose if pressure fails to stop the bleeding. The parent should have the child sit up and lean forward to avoid aspiration of blood when the nose starts bleeding. TEST-TAKING TIP: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses.

While assessing the skin of a patient, the nurse suspects hypoxia. Which skin discoloration led the nurse to this conclusion?

*A. Bluish B. Reddish C. Tan-brown D. Yellowish orange RATIONALE: An increased amount of deoxygenated hemoglobin is associated with hypoxia. Hypoxia is caused by heart or lung disease and/or a cold environment and manifests in bluish skin. Reddish skin may be caused by sudden trauma or fever. Tan-brown skin may be the result of a suntan or pregnancy. Jaundice manifests as yellowish orange skin.

The nurse teaches a patient about cranial nerves to help explain why the right side of the patient's mouth droops instead of moving up into a smile. Which nerve does the nurse explain to the patient?

*A. Facial (VII) B. Trigeminal (V) C. Hypoglossal (XII) D. Spinal accessory (XI) RATIONALE: The facial nerve innervates the sensory and motor functions of the face above the brow, the cheeks, and the chin and controls face symmetry and smile. STUDY TIP: Memorizing the branches of the facial nerve may help you recall its range. One mnemonic is "tiny zebras bit my chin" for "temporal, zygomatic, buccal, mandibular and cervical" branches. Although there are five branches, the cranial nerve number is VII, so picture a VII on the side of your face.

A patient is diagnosed with osteopenia. What does the nurse expect to find in this patient?

*A. Low bone mass of the hip B. Increased lumbar curvature C. Deterioration of bone tissue D. Exaggeration of the posterior curvature of the thoracic spine RATIONALE: Osteopenia is characterized by low bone mass of the hip. An increased lumbar curvature is known as lordosis. Osteoporosis is a systemic skeletal condition with decreased bone mass and deterioration of bone tissue. Kyphosis is an exaggeration of the posterior curvature of the thoracic spine.

A patient has received an eye examination in the emergency room. After an initial assessment, the nurse finds that the patient can clearly see close objects but cannot see distant objects. Which condition does the patient have?

*A. Myopia B. Hyperopia C. Presbyopia D. Retinopathy RATIONALE: The patient has myopia in which the patient can see close objects but not distant objects. Myopia is also called nearsightedness. In cases of myopia, rays of light enter the eye and focus in front of the retina. In hyperopic condition, the patient can clearly see distant objects, but not close objects. Presbyopia is impaired near vision, which is commonly found in middle-aged and older adults. Retinopathy is a noninflammatory eye disorder resulting from changes in the retinal blood vessels.

What is myopia?

*A. Nearsightedness B. Increased opacity of the lens C. Farsightedness D. Impaired near vision in middle and older adults RATIONALE: Myopia, or nearsightedness, is a refractive error of the eye in which rays of light enter the eye and focus in front of the retina. Patients with this condition can see close objects clearly but not distant objects. Cataract is increased opacity of the lens, which blocks light rays from entering the eye. Hyperopia is farsightedness, also a refractive error, but one in which light rays focus behind the retina. Presbyopia is impaired near vision in middle and older adults caused by loss of elasticity of the lens.

Which cranial nerve has only sensory function?

*A. Olfactory B. Trigeminal C. Oculomotor D. Glossopharyngeal RATIONALE: The olfactory nerve has only sensory function. The trigeminal and glossopharyngeal nerves have both sensory and motor functions. The oculomotor nerve has only motor function. TEST-TAKING TIP: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse is performing a Mini-Mental State Examination (MMSE) on an intoxicated patient. Which parameters will the nurse evaluate in the patient? Select all that apply.

*A. Orientation *B. Cognitive registration C. Risk of developing cancer D. Risk of developing seizures E. Levels of alcohol in the blood RATIONALE: The Mini-Mental State Examination (MMSE) is an instrument developed by Folstein et al. It provides information regarding a patient's orientation and cognitive function. It cannot provide information regarding risk of cancer, seizures, and alcohol blood level. TEST-TAKING TIP: In reading the question carefully, you should notice the word Mental in the name of the exam. Then examine which choices are geared to mental evaluation to reveal that only orientation and cognitive registration apply.

During an assessment, the nurse uses the sense of touch with the surface of the hand to collect clinical data. Which technique is this?

*A. Palpation B. Inspection C. Percussion D. Auscultation RATIONALE: Palpation is using the sense of touch to detect temperature, moisture, texture, and turgor. Inspection involves carefully looking and listening to distinguish normal from abnormal findings. Percussion is tapping the skin to vibrate underlying tissues and organs. This procedure helps to locate masses or organs and determine their size. Auscultation involves listening to sounds of the body to detect variations.

The nurse is examining the thorax and lungs. Which technique used by the nurse would be beneficial in measuring excursion and fremitus?

*A. Palpation B. Inspection C. Percussion D. Auscultation RATIONALE: Palpation uses the sense of touch to assess and collect data. It is used to measure excursion and fremitus while examining the thorax. During the inspection, the nurse should carefully look, listen to, and smell the abnormal findings. Tapping the skin with the fingertips to vibrate underlying tissues and organs is called percussion. Auscultation is beneficial for hearing the lung sounds.

Using light pressure with the index and middle fingers, the nurse cannot palpate any of the patient's superficial lymph nodes. What should the nurse do next?

*A. Record this finding as normal. B. Reassess the lymph nodes using deeper pressure. C. Ask the patient about any history of radiation therapy. D. Notify the health care provider that x-rays of the nodes will be necessary. RATIONALE: Superficial lymph nodes are evaluated by light palpation, but they are not normally palpable. It may be normal to find small (less than 1.0 cm), mobile, firm, nontender nodes. Applying deeper pressure may not help in palpating superficial lymph nodes. A history of radiation therapy does not affect lymph nodes. Deep lymph nodes are detected radiographically.

The registered nurse instructs the nursing student to avoid deep palpations while performing physical assessment of the patient's thorax region. Which condition observed by the registered nurse supports the instruction?

*A. Rib fractures B. Intercostal muscle spasm C. Costal cartilage calcification D. Respiratory muscle atrophy RATIONALE: Patients with rib fractures are contraindicated for deep palpations, because the fractured fragments may displace against vital organs. Patients who have intercostal muscle spasms may not be contraindicated for deep palpations. Costal cartilage calcification and respiratory muscle atrophy indicate reduced chest excursion in older adults, but may not be contraindicated for deep palpations.

Turgor is related to the elasticity of the skin. What is the effect on the skin when a patient has poor turgor?

*A. The skin stays pinched. B. The skin has an edematous area. C. The skin has ruby red papules. D. The skin falls immediately back to its original position. RATIONALE: In poor turgor, the skin stays pinched. An edematous area is observed in the case of skin edema. Ruby red papules on the skin indicate skin lesions. Normal skin falls immediately back to its original position.

During a skin assessment, the nurse observes that the patient's skin lifts easily and falls immediately back to its resting position. What should the nurse interpret from this assessment?

*A. This is a normal skin finding. B. This indicates dehydration. C. This indicates pitting edema. D. This indicates lost skin vascularity. RATIONALE: If the skin is lifted and falls back immediately, this indicates a normal skin finding. This test is used to assess the elasticity or the turgor of the skin. In case of dehydration, the skin fails to reassume its normal contour or shape after the skin is lifted and released. When pressure from the examiner's fingers leaves an indentation in the edematous area, it is called pitting edema. Loss of skin vascularity may be evident through pale skin. TEST-TAKING TIP: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

During a skin assessment, the nurse observes that the patient's skin lifts easily and falls immediately back to its resting position. What should the nurse interpret from this assessment?

*A. This is a normal skin finding. B. This indicates dehydration. C. This indicates pitting edema. D. This indicates lost skin vascularity. RATIONALE: If the skin is lifted and falls back immediately, this indicates a normal skin finding. This test is used to assess the elasticity or the turgor of the skin. In case of dehydration, the skin fails to reassume its normal contour or shape after the skin is lifted and released. When pressure from the examiner's fingers leaves an indentation in the edematous area, it is called pitting edema. Loss of skin vascularity may be evident through pale skin. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Why might a nurse ask a patient if he or she snores at night?

*A. To identify septal deviation B. To determine the presence of infections C. To explain asymmetry of the external nose D. To determine the source of nasal and sinus drainage RATIONALE: The nurse would ask the patient about snoring at night to determine if the patient has a septal deviation or obstruction. In order to determine the presence of infections and allergies, the nurse would ask the patient about nasal discharge. In order to explain asymmetry of the external nose, the nurse would ask about a history of trauma to the nose. In order to determine the source or nature of nasal and sinus drainage, the nurse would ask the patient about a history of allergies or postnasal drip. TEST-TAKING TIP: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

Which lesion is the result of a mosquito bite?

*A. Wheal B. Papule C. Macule D. Pustule RATIONALE: A wheal is an irregularly shaped, superficial localized edema that varies in size and is caused by a hive or a mosquito bite. A papule is a palpable, solid elevation in the skin. A macule is a flat, nonpalpable change in skin color like freckles or petechiae. A pustule is circumscribed elevation of skin that is filled with pus and may occur due to staphylococcal infection.

A nurse is preparing to assess a patient's abdomen, genitalia, and rectum. Which nursing intervention is the most appropriate in this situation?

A. Asking the patient to assume prone position B. Changing latex gloves to vinyl or nitrile gloves C. Asking the patient to assume lateral recumbent position *D. Asking the patient if he or she needs to use the restroom RATIONALE: Before assessing a patient's abdomen, genitalia, and rectum, the nurse should ask if the patient needs to use the restroom, because an empty bladder and bowel facilitate the examination. Prone position is desirable if the nurse is assessing the patient's extension of hip joint, skin, and buttocks. The nurse should change latex gloves to vinyl or nitrile gloves if the patient is allergic to latex. While assessing a patient's heart, the nurse should ask the patient to assume lateral recumbent position.

A patient is admitted to the hospital with an intestinal obstruction. The surgical nurse records the vitals and starts to examine the patient's abdomen. In which order should the nurse conduct the examination? Arrange the activities in the correct order.

1. Consent from the patient 2. Inspection of abdomen 3. Auscultation of abdomen 4. Palpation of abdomen RATIONALE: The nurse must receive consent before performing any procedure on a patient. It is recommended that the nurse take a clinical history and do the physical examination of the abdomen afterward. During the abdominal assessment, auscultation of the abdomen should be done before palpation because manipulation of the abdomen alters the frequency and intensity of bowel sounds. The best time to auscultate is between meals. Absent sounds indicate a lack of peristalsis, possibly the result of bowel obstruction (late stage), paralytic ileus, or peritonitis. TEST-TAKING TIP: Remember that the order of examination techniques moves from least invasive to most invasive as the examination progresses.

The nurse plans to assess the patient's abstract reasoning. Which should the nurse ask the patient?

A. "Tell me where you are." B. "What can you tell me about your illness?" C. "Repeat these numbers back to me: 7; 5; 8." *D. "What does this mean: 'A stitch in time saves nine?'" RATIONALE: Abstract reasoning requires cognitive functioning and the ability to identify relationships between concepts. Asking the patient what "A stitch in time saves nine" means encourages the patient to use higher intellectual function. Asking a patient where they are, about their illness, and repeating numbers does not require abstract thinking but does require knowledge and memory.

The nurse is assessing a patient's extraocular movements. At which distance should the nurse direct the patient to sit or stand during the assessment?

A. 1 cm B. 31 cm *C. 60 cm D. 4 cm RATIONALE: The nurse should direct the patient to stand or sit 60 cm away while assessing the patient's extraocular movements. The other distances, 1 cm, 31 cm, and 4 cm, are too shallow for accurate assessment of extraocular eye movements. TEST-TAKING TIP: Multiple choice questions can be challenging, because students think they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Jaundice produces a yellow-orange discoloration of body tissues. Which body part is the best site for the nurse to inspect for jaundice?

A. Lips *B. Sclera C. Mouth D. Tongue RATIONALE: The best site to inspect for signs and symptoms of jaundice is the sclera, or the mucous membranes. Inspection of the lips, mouth, and tongue is not as helpful for assessment of jaundice because discoloration of these structures occurs relatively late in the disease process.

Which sign best indicates strabismus in a patient?

A. Blurred vision B. Impaired near vision due to aging *C. Inability to focus both eyes on an object simultaneously D. Inability to see close objects but able to see distant objects RATIONALE: Strabismus is a condition in which the patient is unable to focus both eyes on an object simultaneously. In this condition, the patient's eyes appear crossed. Cataracts or macular degeneration of the eye causes blurred vision. Impairment of near vision due to aging is a sign of presbyopia. If the patient cannot see close objects but can see distant objects, the condition is called hyperopia. STUDY TIP: Identify your problem areas that need attention for studying. Do not waste time restudying information you know

What is an early indication that a patient may be developing caries?

A. Brown teeth *B. Chalky white teeth C. Stained yellow teeth D. White and shiny teeth RATIONALE: A white chalky color of tooth enamel is an early sign of dental caries. A brown color indicates that the caries are well established beyond their early stages. Yellow staining can be due to the use of tobacco, tea, coffee, and colas. White and shiny teeth are healthy.

A patient is suspected to have dehydration. How should the nurse assess the elasticity of the skin?

A. By using a light palpation method anywhere on the body B. By inspecting edematous areas on the skin C. By inspecting reddened, pink, or pale areas on the skin *D. By folding the skin of the forearm with the fingertips and releasing it RATIONALE: Elasticity of the skin refers to the ability of the skin to reassume the normal contour or shape after being pinched and released. Good elasticity is a sign of adequate hydration and can be checked by grasping a fold of the skin on the back of the forearm or over the sternum with the fingertips and then releasing it. If the patient is dehydrated, the skin remains in the pinched position and shows tenting. Light palpation is used for palpating superficial structures for tenderness. It is not helpful for checking the skin's elasticity. Inspecting the edematous, or swollen, areas on the skin is not helpful for checking the skin's elasticity. Inspection of the reddened, pink, or pale areas on the skin is helpful for assessing the blood supply (vascularity) of the skin, but not for checking elasticity.

The nurse is measuring the body temperature of a patient. How can the nurse check a patient's body temperature using a palpation technique?

A. By using deep palpation B. By using only the pads of the fingers *C. By using the dorsal surface of the hand D. By using the palmar surface of the hand RATIONALE: The dorsal surface of the hand is used to check body temperature, which gives a relative measurement (high or low) of the body temperature. A thermometer is needed to get the exact measurement of the body temperature. Deep palpation is used to examine the condition of organs such as those in the abdomen. The pads of the fingers are used to check swelling, symmetry, and mobility of glands but are not as reliable in gauging temperature. The palmar surface is used to determine position, texture, size, consistency, masses, fluid, and crepitus.

The nurse is performing examination of the lungs and thorax of a patient. From which area should the nurse begin palpation of tactile fremitus?

A. Clavicle *B. Lung apex C. Angle of Louis D. Base of the lung RATIONALE: Palpation of tactile fremitus is started at apex of the lung. The clavicle is used to draw imaginary lines which are used for lung and thorax assessment. The Angle of Louis is a visible and palpable angulation of the sternum. It is the point at which the second rib articulates with the sternum. Palpation of tactile fremitus ends at base of lung.

Which characteristics of the hair are associated with diabetes and thyroiditis?

A. Dry and brittle B. Fine and brittle C. Stringy and dull *D. Thinning RATIONALE: Endocrine disorders such as diabetes and thyroiditis can cause the hair to thin, a condition called alopecia. Dry and brittle hair is associated with aging and excessive use of chemicals. Thyroid disease can cause fine and brittle hair. Stringy and dull hair is a manifestation of poor nutrition.

What could be the cause of adventitious lung sounds characterized by high-pitched, continuous musical sounds?

A. Fluid or mucus in larger airways B. Parietal pleura rubbing against visceral pleura C. Random, sudden reinflation of groups of alveoli *D. High-velocity airflow through severely narrowed or obstructed airway RATIONALE: Wheezes are high-pitched, continuous musical sounds heard during inspiration. High-velocity airflow through a severely narrowed or obstructed airway may cause wheezes. Fluid or mucus in larger airways may cause rhonchi. Parietal pleura rubbing against visceral pleura may cause pleural friction rub. Random, sudden reinflation of groups of alveoli may cause crackles.

The nurse is performing a musculoskeletal examination of a patient. Which joint will the nurse ask the patient to put through eversion motion?

A. Hip *B. Foot C. Hand D. Finger RATIONALE: Eversion is the turning of a body part away from midline; the foot can be put through this motion. The hip can be put through motions like internal and external rotation. The hand can be put through movements like pronation and supination. The finger can be put through motions like extension, abduction, and adduction.

A patient is brought to the emergency department following a motor-vehicle accident. The nurse assesses the patient's level of consciousness using a Glasgow Coma Scale (GCS). Which parameters does this test evaluate? Select all that apply.

A. Lateralization of sound *B. Opening of eyes *C. Verbal response *D. Motor response E. Air and bone conduction RATIONALE: The parameters tested in the Glasgow Coma Scale (GCS) include opening of eyes in response to commands, as well as verbal and motor response to commands. A fully conscious patient responds to questions quickly and expresses ideas logically. The lateralization of sound is assessed by Weber's test. Air and bone conduction in the ears is assessed by the Rinne test.

While assessing the eyelids of a patient, the nurse suspects the patient has nystagmus. Which finding may have led the nurse to this suspicion?

A. Lid margins that are turned out B. Redness in the conjunctivae C. Abnormal drooping of the lid over the pupil *D. Involuntary and rhythmical oscillations of the eyes RATIONALE: Involuntary and rhythmical oscillation of the eyes as a result of local injury to the eye muscle is characteristic of nystagmus. Lid margins that are turned out are characteristic of ectropion. Redness and inflammation of the conjunctivae indicate conjunctivitis. An abnormal drooping of the eyelids over the pupil is characteristic of ptosis.

Which condition is associated with an exaggeration of the posterior curvature of the thoracic spine?

A. Lordosis B. Scoliosis *C. Kyphosis D. Osteoporosis RATIONALE: Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Osteoporosis is a systemic skeletal condition with decreased bone mass and deterioration of bone tissue, making bones fragile and at risk for fracture.

What is the common imaginary line observed in anterior and lateral chest landmarks?

A. Midaxillary line B. Midclavicular line C. Right scapular line *D. Anterior axillary line RATIONALE: The anterior axillary line is the common imaginary line observed in anterior and lateral chest landmarks. The midaxillary line is the imaginary line observed in the lateral chest landmark. The midclavicular line is the imaginary line observed in the anterior chest landmark. The right scapular line is the imaginary line observed in the posterior chest landmark.

Which statement regarding hearing acuity in older adults is true?

A. Older adults hear high-frequency sounds best. *B. Older adults are at risk of hearing loss caused by auditory nerve injury. C. Older adults may lose the ability to hear vowel sounds. D. Swelling of the auditory canal can cause older adults to gradually lose hearing acuity RATIONALE: Older adults are at risk for hearing loss due to auditory nerve injury, a condition called ototoxicity, which results from high doses of certain antibiotics. Older adults may have trouble hearing high-frequency sounds and consonant, not vowel, sounds. Deterioration of the cochlea and thickening of the tympanic membrane, not swelling of the auditory canal, can cause older adults to gradually lose hearing acuity.

The nursing student is performing an assessment of the anterior thorax of a patient placed in a supine position. Which condition might result, requiring correcting the position of the patient?

A. Pain in joints B. Embarrassment C. Discomfort *D. Difficulty in breathing RATIONALE: A supine position may cause a patient to experience shortness of breath or difficulty in breathing easily if the patient has a respiratory disorder like asthma. Sims' position requires flexion of hips and knees, which may be painful or uncomfortable for some patients. Lithotomy position, used for examining the genitals, can cause a patient embarrassment. TEST-TAKING TIP: Look for answers that focus on the patient or are directed toward feelings.

A patient comes to the clinic for a regular checkup. The nurse is performing a physical examination on the patient. Which intervention should the nurse perform during palpation?

A. Palpate the tender areas first. B. Ask the patient to take shallow breaths. C. Instruct the patient to keep both hands on the abdomen. *D. Warm the hands and use a gentle approach. RATIONALE: The nurse should perform palpation by warming the hands and using a gentle approach. Cold hands can cause the muscle to contract and interfere with palpation. Tender areas should be palpated last, because this is painful for the patient. The patient should be instructed to take deep breaths to help the patient to relax. The patient should keep the hands at the sides to prevent interference with the palpation. TEST-TAKING TIP: Key words or phrases in the stem of the question and in the choices, such as first, primary, early, or best are important. Knowing that tender areas should be palpated last (not first) would help you eliminate one of the choices.

A nurse taps a patient's skin with the fingertips to vibrate underlying tissues and organs. Which physical assessment technique is the nurse using?

A. Palpation B. Inspection *C. Percussion D. Auscultation RATIONALE: Percussion is the tapping of skin with the fingertips to vibrate underlying tissues and organs. Palpation is the use of different parts of the hand to detect characteristics of the body parts. Inspection involves the use of visual, hearing, or olfactory ability to assess a patient's body. Auscultation refers to listening to the sounds the body makes to detect variations from normal.

A nurse uses the bell of a stethoscope to hear a patient's heart sounds. Which physical examination technique of is the nurse using?

A. Palpation B. Inspection C. Percussion *D. Auscultation RATIONALE: Auscultation refers to using a stethoscope to listen to internal body sounds. The bell of a stethoscope is used for hearing low-pitched sounds, such as heart sounds. Palpation is the use of different parts of the hand to detect different characteristics of body parts. Inspection involves the use of visual, hearing, or olfactory abilities to assess a patient's body. Percussion involves the use of the fingertips to tap the skin and assess underlying tissues and organs of a patient's body.

During the physical examination of a patient, the nurse listens to the heart sounds to detect variations from normal. Which physical examination technique is the nurse performing?

A. Palpation B. Inspection C. Percussion *D. Auscultation RATIONALE: The nurse is performing auscultation. Auscultation involves listening to the sounds of the body to detect abnormalities. Palpation is used to make judgments about abnormal and normal findings of the skin or underlying tissue, muscle, and bones. In the inspection technique, the nurse observes the size, shape, color, symmetry, position, and abnormality of various body parts. Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and organs.

While examining a patient's skin, the nurse finds a circumscribed elevated solid mass that is deep and firm. The lesion is 1 to 2 cm in diameter. What is this mass called?

A. Papule B. Vesicle *C. Nodule D. Pustule RATIONALE: A nodule is an elevated solid mass that is deeper and firmer than a papule. The size of the lesion is around 1 to 2 cm in diameter. A papule is a palpable, circumscribed, solid elevation in the skin that is smaller than 1 cm. A vesicle is a circumscribed elevation of the skin filled with serous fluid and less than 1 cm in diameter. A pustule is a circumscribed elevation of skin that is similar to vesicle, but filled with pus and variable in size.

A nurse is preparing to examine a patient's rectum. Which position should the nurse ask the patient to assume?

A. Prone *B. Knee-chest C. Dorsal recumbent D. Lateral recumbent RATIONALE: While assessing the rectum, the nurse should ask the patient to assume knee-chest position, because this position provides maximum exposure of the rectal area. While assessing the extension of hip joint, skin, and buttocks, the patient should be asked to assume prone position. While assessing the abdomen, the patient should be asked to assume dorsal recumbent position. While assessing the heart, the patient should be asked to assume lateral recumbent position.

Which position provides easy access to a patient's pulse sites during a physical examination?

A. Prone *B. Supine C. Lithotomy D. Dorsal recumbent RATIONALE: The supine position provides easy access to pulse sites. The prone position is most suitable for assessing the musculoskeletal system. The lithotomy position is most suitable for assessing the female genitalia and genital tract. The dorsal recumbent position is most suitable for assessing the abdomen.

A nursing student is performing a respiratory assessment on a patient who is suspected to have asthma. Placing the patient in which position would increase the risk of shortness of breath?

A. Prone position *B. Supine position C. Sims' position D. Lateral recumbent position RATIONALE: Sitting, supine, and dorsal recumbent positions are helpful for assessing the thorax and lungs. Shortness of breath is a sign of asthma. If the patient with asthma is placed in the supine position, that patient may experience shortness of breath. To reduce this, the head of the bed should be elevated. Therefore, placing the patient with asthma in supine position may increase the risk of shortness of breath. Prone position is used to assess the musculoskeletal system. Sims' position is used to assess the rectum and vagina. Lateral recumbent position is used to assess the heart. TEST-TAKING TIP: Look for answers that focus on the patient or are directed toward feelings.

What is the color of a normal tympanic membrane?

A. Red B. Pink C. White *D. Gray RATIONALE: The color of a normal tympanic membrane is pearly gray. If the tympanic membrane is red or pink, it is likely inflamed. If it is white, pus may be behind it.

Which sounds are considered normal breath sounds?

A. Rhonchi B. Crackles C. Wheeze *D. Bronchia RATIONALE: Bronchial sounds are normal breath sounds. Rhonchi, crackles, and wheeze are the normal adventitious breath sounds.

While assessing a patient, the nurse felt strong vibrations on the chest wall after palpating. What does this finding indicate?

A. Rhonchi B. Crepitus *C. Fremitus D. Friction rub RATIONALE: Tactile or vocal fremitus refers to the sound waves that create strong vibrations by reaching the chest wall. Rhonchi are the adventitious sounds that are coarse and low pitched, which are heard during auscultation. Crepitus is a grating sound produced by friction between bone and cartilage or the fractured parts of a bone. Friction rub is the adventitious sound heard during auscultation that is scratchy and high pitched.

Which part of the ear is present in the external region?

A. Stapes B. Cochlea C. Malleus *D. Mastoid RATIONALE: The mastoid is located in the external region of the ear. The stapes and malleus are located in the middle ear. The cochlea is located in the inner ear.

A patient is scheduled for angiography. The nurse observes that the patient is anxious and unwilling to sit through the procedure. What would be the most appropriate nursing action?

A. Suggest the patient change positions and resume the angiography. *B. Reschedule the angiography and provide more information about the procedure. C. Force the patient to cooperate as per the schedule. D. Ask a family member to calm the patient down before starting the procedure RATIONALE: The patient is anxious because of the angiography procedure, which may make it impossible for the patient to cooperate with the procedure. The most appropriate action in such cases is to postpone the angiography and provide more information to the patient to calm the patient's fears. Suggesting that the patient change positions will not decrease anxiety. The nurse should avoid forcing the patient to cooperate as per schedule, because the findings will not be accurate. Although the patient may take comfort in talking to family members before the procedure, the nurse should not rely solely on the family members to calm the patient down. Instead, the nurse should take an active role in soothing the patient and addressing any concerns about the procedure. TEST-TAKING TIP: Look for answers that support patient-centered care. For this question, the only choice that supports the patient is the correct response.

Which characteristic of the skin is measured using the dorsum of the hand?

A. Texture B. Moisture C. Tenderness *D. Temperature RATIONALE: Temperature of the skin is measured using the dorsum of the hand. The palmar surface of the hand is used to assess texture and moisture of the skin. Tenderness can be assessed with the finger pads or palmar surface of the hand.

The nurse inspects a patient's nails and finds that the nails have concave curves. What could the nurse infer from this observation?

A. The patient's nails are normal. *B. The patient has anemia. C. The patient has a nail injury. D. The patient has a local infection. RATIONALE: The condition of the nails reflects the overall health and nutrition of an individual. Concave curves on the nails are not a normal finding and indicate that the patient has anemia. In nail injury, transverse depressions, or Beau's lines, may be observed in the nails. Inflammation of the skin at the base of the nail indicates a local infection and is referred to as paronychia.

Upon assessment, why might a nurse ask a patient if his or her nose has experienced recent trauma?

A. To determine the nature of nasal discharge B. To determine the presence of infection or allergy C. To determine causes of physical change in the mucosa. D. To determine causes of septal deviation and asymmetry of the external nose. RATIONALE: If the nurse observes septal deviation and asymmetry of the external nose, he or she may ask if the patient has a history of trauma to the nose, which is a likely cause for the abnormality. Asking about the presence of allergies, nasal discharge, and nosebleeds would be helpful in determining the source and nature of nasal and sinus discharge. If the patient has a history of nasal discharge, then the nurse should assess the color, amount, odor and duration of the associated symptoms, which helps rule out or identify the presence of infection, allergy, or drug use. The nurse may ask if the patient uses nasal sprays or drops because overuse of over-the-counter nasal preparations can cause physical changes in the mucosa.

When examining a patient from behind, which anatomic chest wall landmark extends down from the center of the neck?

A. Vertebral line B. Midaxillary line *C. Midsternal line D. Midclavicular line RATIONALE: When examining a patient from behind, the vertebral line is the chest wall landmark that extends down from the center of the neck. The midaxillary line extends down from the center of the neck when viewing the patient from the side. The midsternal line extends down from the center of the neck when viewing the patient from the front, and the midclavicular line is apparent from this view lateral to the midsternal line.

A patient is exhibiting pallor of the face, conjunctivae, nail beds, and palms of the hands. What condition might this patient be experiencing?

A. Vitiligo *B. Anemia C. Jaundice D. Shock RATIONALE: Pallor of the face, conjunctivae, nail beds, and palms of the hands is a physical finding of anemia. Vitiligo is evident in patchy discoloration of the skin over a patient's face and arms. Jaundice manifests as yellow discoloration of the skin, sclera, and mucous membranes. Shock also results in pallor, but it is typically of the skin, nail beds, conjunctivae, and lips.